more_vertDespite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities.
Preference: Statistics, epidemiology and research design
1138
News briefs
Hidden risk population for thunderstorm asthma
Research presented at the Thoracic Society for Australia and New Zealand (TSANZ) Annual Scientific Meeting in Canberra last month identified “a potentially hidden and significant population susceptible to thunderstorm asthma”. “This is a wake-up call for all of Australia, but particularly Victoria as it prepares for its next pollen season,” said Professor Peter Gibson, president of TSANZ. “Many more people than previously thought are at risk of sudden, unforeseen asthma attack. It is essential that we invest more research into this phenomenon and educate our health services and public to take preventative and preparedness measures.” Nine people died in Victoria late last year and over 8500 required emergency hospital care when a freak weather event combining high pollen count with hot winds and sudden downpour led to the release of thousands of tiny allergen particles triggering sudden and severe asthma attacks. Those most seriously affected were people who were unaware they were at risk of asthma and therefore had no medication to hand. In the study of over 500 health care workers, led by the Department of Respiratory and Sleep Medicine, Eastern Health, Victoria, almost half the respondents with asthma experienced symptoms during the thunderstorm event. Most took their own treatment, a few sought medical attention and one was hospitalised. More alarming was the 37% of respondents with no prior history of asthma who reported symptoms such as hayfever, shortness of breath, cough, chest tightness and wheeze during the storms. The study also found that people with a history of sensitivity to environmental aeroallergens (eg, ryegrass or mould) were far more likely to report symptoms than those with a history of either no allergy or allergy to dust mite/cats. Physical location, described as predominantly indoors versus outdoors, was not a risk factor. “This study gives us an indication of the proportion of our population that might be at risk of thunderstorm asthma, but are unaware of it as they have no history of asthma. It also suggests that a history of hayfever is one of the greatest risk factors,” said lead researcher Dr Daniel Clayton-Chubb. “The key message from our work is that anyone with hayfever should ensure that they have ready access to quick-acting asthma treatments such as bronchodilators at all times, but particularly in pollen season or if thunderstorms are predicted. Severe thunderstorm asthma symptoms can strike rapidly and without warning.”
New genetic causes of ovarian cancer identified
A major international collaboration has identified new genetic drivers of ovarian cancer, findings which have been published in Nature Genetics. The study involved 418 researchers from both the Ovarian Cancer Association Consortium, led by Dr Andrew Berchuck from the United States, and the Consortium of Investigators of Modifiers of BRCA1/2, led by Professor Georgia Chenevix-Trench from QIMR Berghofer Medical Research Institute. Professor Chenevix-Trench said it was known that a woman’s genetic make-up accounts for about one-third of her overall risk of developing ovarian cancer. “This is the inherited component of the disease risk,” Professor Chenevix-Trench said. “Inherited faults in genes such as BRCA1 and BRCA2 account for about 40% of that genetic risk. Other variants that are more common in the population (carried by more than one in 100 people) are believed to account for most of the rest of the inherited component of risk. We’re less certain of environmental factors that increase the risk, but we do know that several factors reduce the risk of ovarian cancer, including taking the oral contraceptive pill, having your tubes tied and having children. In this study, we trawled through the DNA of nearly 100 000 people, including patients with the most common types of ovarian cancer and healthy controls. We have identified 12 new genetic variants that increase a woman’s risk of developing the cancer. We have also confirmed that 18 variants that had been previously identified do increase the risk. As a result of this study, we now know about a total of 30 genetic variants in addition to BRCA1 and BRCA2 that increase a woman’s risk of developing ovarian cancer. Together, these 30 variants account for another 6.5% of the genetic component of ovarian cancer risk.”
[Department of Error] Department of Error
Rona RJ, Burdett H, Khondoker M, et al. Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: a cluster randomised controlled trial. Lancet 2017; 389: 1410–23—In this Article, “The US Congressionally Directed Medical Research Programs” has been corrected to “The US Army Medical Research and Material Command–Military Operational Medicine Research Program (USAMRMC–MOMRP)” in the Funding, Declaration of interests, and Acknowledgments sections. The Acknowledgments section has also been updated to include details of funding from the National Institute for Health Research to SW and MK, and to acknowledge that views expressed are those of the authors only.
Post-Traumatic Stress – the Tony Dell story
Tony Dell is the only living Australian to have played Test cricket and served in active combat. Selected by Sir Donald Bradman as Australia’s 255th Test cricketer, Dell, a tall left-arm fast bowler, played two Tests under legendary captain Ian Chappell. His debut was against England in the seventh Test at Sydney (1970-71), where he took five wickets; opening the bowling with Dennis Lillee. Dell claimed six Test wickets at 26.66, and took 41 first-class wickets at 26.70 (best 6/17) before retiring at just 27 years old.
Back in 1965, long before his Test and Queensland Sheffield Shield career began, a young Tony Dell was called up for National Service, and served in 2RAR (2nd Battalion, Royal Australian Regiment) in Vietnam from 1967-68.
About 10 years ago, Tony walked into the office of Mental Health Australia (where I was Director of Communications) and told me he had post-traumatic stress. He wanted to do something to help veterans and others who experience this condition. PTS (many feel the word ‘disorder’ stigmatises those with the condition), as Tony Dell’s website explains, is “contracted when the human brain is subjected to some sort of adverse experience, tragic event or fear that it wasn’t built to withstand. Many humans can be subjected to events that can cause this condition. In fact, nearly all of us can experience some sort of event which will challenge our senses. This can have just a short-term effect or it can be long lasting, depending on the person and the event.”
For those with PTS, the memory of traumatic events can be suppressed into the subconscious. If the event isn’t dealt with, it can foment and affect the person’s life in debilitating ways. Symptoms can appear gradually without the person really noticing or being aware of the cause.
Tragically, for many war veterans and others who have untreated PTS, suicide is too often the outcome. It is reported that in the past decade Australia has lost more veterans to suicide than killed on the battlefield. Tony’s story – from Test cricketer to divorce, and family problems – is commonplace for many veterans, but also for police, SES volunteers, firefighters and those who experience trauma through violence, accidents or natural disasters.
What Tony Dell did to change this should be an episode of Australian Story. From absolutely nothing, he created StandTall4PTS [http://standtall4pts.org/], a unique campaign that has brought together the Australian Defence Force, police, sporting celebrities and others to raise awareness of PTS. StandTall4PTS has Sir Angus Houston, retired CDF, as patron. His campaign has been endorsed and supported by Prime Ministers, Test cricketers and leading sportspeople.
Dell’s aim is to ensure that medical practitioners and community health services understand what PTS is, how it impacts on the families and friends of those who experience it, and to ensure there are properly funded and appropriate resources in place for people with PTS.
The problem with PTS is that it is often couched within mental health, although many experts believe this isn’t how we should understand and respond to PTS. Although there is no definitive data available, some estimates are that about 1.5 million Australians have PTS to some extent.
In an interview with CricInfo, Dell said this about living with PTS: “It can be bad dreams, flashbacks, night sweats, teeth grinding, fear of being in crowds. For 20 or 30 years if I went into a room or a restaurant or something, I’d sit with my back to a wall facing out. You can become a workaholic. I know in my case I’d get up at the crack of dawn, go to work and wouldn’t come home until late at night because you’re subconsciously keeping yourself busy and shutting out times when you can sit and think. A lot of guys can’t handle it and start hitting the booze or drugs, substance abuse, and then it gets too much for a lot of people.”
When I met Tony Dell, he had only recently been diagnosed with PTS. It was only through his local Vietnam Veterans Drop-In Centre that he discovered what had affected him for decades. Anecdotally, there are many similar stories of people with undiagnosed PTS who churn in and out of various health services because of a lack of awareness and understanding of this condition.
Today, Tony Dell runs a nationwide campaign to improve research to increase our understanding of PTS and ensure better pathways for help and treatment for those affected and their families.
SIMON TATZ, AMA, DIRECTOR, PUBLIC HEALTH
AMA contributes to new guidelines
Two members of the AMA policy team have been thanked for their contributions to the first edition of the Guidelines for on-screen presentation of discharge summaries, developed by the Australian Commission on Safety and Quality Health Care.
Chair of the AMA Council of General Practice, Dr Richard Kidd, and Chair of the AMA Ethics and Medico Legal Committee Dr Chris Moy both took part in developing the guidelines.
Chief Executive Officer of the Commission, Adjunct Professor Debora Picone, expressed her gratitude to the doctors in a recent letter to AMA President Dr Michael Gannon.
“Development of the guidelines was supported by a clinical expert group that included and informed through an extensive national consultation,” Professor Picone wrote.
“I would like to take this opportunity to thank Dr Richard Kidd and Dr Chris Moy from the Australian Medical Association who contributed to this important work.”
The Guidelines for on-screen presentation of discharge summaries are available on the Commission’s website at: https://www.safetyandquality.gov.au/publications/national-guidelines-for…
According to the site, the guidelines specify the sequence, layout and format of the core elements of hospital discharge summaries, as displayed in clinical information systems.
They were developed through extensive research, consultation and iterative testing with more than 70 clinicians.
The guidelines are intended to be adopted by vendors of medical software, and health services that procure and implement systems which generate and present discharge summaries.
“The clinical handover of a patient on discharge from hospital generally occurs using an electronic discharge summary (eDS),” the guidelines say.
“A discharge summary is a collection of information about events during care of a patient by a provider or organisation, in a document produced during a patient’s stay in hospital, as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.
“Clinical handover is a known area of potential risk for patient harm, particularly in the transition from acute care to the community setting. Discharge summaries are critical for providing well-coordinated and effective clinical handover because they are the primary communication mechanism between hospitals and primary health care providers.”
In July 2012, the Commission was appointed to develop and manage a clinical safety program for the My Health Record system, which is a secure online summary of health information, personally controlled by individuals.
Patients’ discharge summaries can be added to their My Health Record. As part of the Commission’s clinical safety program, eight clinical safety reviews of the My Health Record system were completed.
The fourth clinical safety review, conducted in 2014, included an end-to-end investigation of the accuracy and data quality of eDS.
The guidelines were endorsed by the National Health Chief Information Officer Forum in August 2016 and presented at the Commission’s Inter-Jurisdictional Committee in October the same year, and are now freely available on the Commission’s website.
Other safety in e-health findings can also be found on the Commission’s website at: https://www.safetyandquality.gov.au/our-work/safety-in-e-health/
Chris Johnson
Do homework before choosing private health insurance
AMA President Dr Michael Gannon has urged health insurance consumers to shop around.
Before buying private health insurance (PHI) or changing insurers, he said, consumers need to be assured they will get value for money.
“Too many Australians aren’t getting value for money,” he said following the release of the AMA Private Health Insurance Report Card 2017.
“A lot are. Private patients admitted to private hospitals around Australia have normally got a very positive story to tell about the care they’ve received.
“But for too many people, when they get sick, when one of their loved ones gets sick, they either find they’re not entitled to treatment in a private hospital, they’re shipped off to the public hospital, or they’re told that there’s going to be a significant delay in treatment or significant out of pocket expenses.
“What the Report Card tries to do is give people an idea about which policies might suit them and their family best.”
Dr Gannon said people should thoroughly research and compare the various and varied policies on offer to ensure they are getting value for money.
More importantly, he said, they should know exactly what they are covered for in the event of accident, illness, or injury.
“Australian families now contribute a substantial proportion of their household income towards private health insurance, so it is important they know exactly what they are getting from their investment,” Dr Gannon said.
“Family budgets are under pressure with cost of living increases, which have been added to with the recent annual increase in PHI premiums.
“The AMA Private Health Insurance Report Card 2017 provides consumers with clear, simple information about how health insurance really works.
“It shows that there are a lot of policies on offer, which provide significantly varying levels of cover, gaps, and management expenses. There are a lot of policies on the market that do not provide the cover patients expect when they need it.
“If people have one of these ‘junk policies’, the AMA encourages them to check their policy matches their current and anticipated health care needs. And, if not, dump it for better cover.
“Our Report Card will help people to understand their product, and allow them to make changes to get better cover and better value for money.
“We show what insurance policies may or may not cover, what the Medicare Benefits Schedule (MBS) covers, and what an out-of-pocket fee may be under different scenarios.
“The Report Card also highlights that private health insurer benefits vary significantly between policies and insurance companies.
“Benefits vary State by State, so this year we’ve highlighted the percentage of hospital charges covered by funds in each State to help consumers better understand what they are buying.
“The percentage of services with no-gap are detailed State by State, and we reveal what each of the PHI funds has reported they spend on management and administration compared to what they pay out as benefits to patients.
“There is data on the level of complaints each fund receives, and we’ve also warned people about the dangers of doctor rating sites.”
Although it is understandable that people are looking to save money, the AMA advises they should not be deceived into downgrading to a junk policy.
From the AMA’s perspective, junk policies should not exist at all.
Dr Gannon said PHI needed to be simplified, more transparent, able to cover the real costs of treatment – including theatre fees, equipment, consumables, hospital costs, and staff time.
“The funds must put the interests of their policyholders first and foremost, and stop pointing the finger at doctors or pushing increased out of pocket costs onto patients when their products do not deliver what patients expect,” he said.
“Benefits for doctors represent less than 10 per cent of the money paid out by Australia’s biggest health insurer.
“We need to ensure that patients retain the right to choose the doctor that is right for them, and to have their treatment at a facility that suits them.
“Equally, we need to ensure that doctors can refer patients to the right specialist – not just the one that an insurer deems appropriate. Insurers do not know the difference between specialist and sub-specialist treatment.
“We must not end up with US-style managed care where a clerk in an office on the other side of the country, not the patient and their doctor, decides what care is affordable.
“Sometimes, preserving that choice might mean treatment in a public hospital. Products must preserve flexibility. Some of our best, most highly-trained doctors work in public hospitals.
“And for those in rural areas, it is often only the public hospital that is available. They should be able to use their insurance product as they need to.
“These decisions – these patient rights – are far too important to be taken away by insurers in an effort to further bolster their profits.
“The AMA wants this Report Card to be a catalyst for greater transparency and clarity from the private health insurers about their products, and a signal to consumers to thoroughly know their PHI product before signing up.”
Since the release of the inaugural AMA Private Health Insurance Report Card in March 2016, the Government has established the Private Health Ministerial Advisory Committee to examine all aspects of private health insurance.
The AMA Private Health Insurance Report Card 2017 is at ama-private-health-insurance-report-card-2017
Chris Johnson
Aussies not eating enough fruit and veg
CSIRO has released findings of Australia’s largest ever survey about the intake of fruits and vegetables.
Its report, Fruit, Vegetables and Diet Score, found one in two Australian adults are not eating the recommended intake of fruit, while two out of three adults are not eating enough vegetables.
Produced by CSIRO and commissioned by Horticulture Innovation Australia, the report compiled the dietary habits of adults across Australia over an 18 month period, involving 145,975 participants nationwide.
It has revealed that most Australians are not as healthy as they think they are.
More people need to eat higher quantities and a greater variety of fruit and vegetables every day to meet the minimum Australian benchmark.
To help meet the benchmark, CSIRO suggests adults eat at least three serves of different vegetables every dinner time.
“Many Aussies believe themselves to be healthy, yet this report shows the majority of those surveyed are not getting all the beneficial nutrients from fruit and vegetables needed for a healthy, balanced diet,” CSIRO Research Director Professor Manny Noakes said.
“Increasing the amount of fruit and vegetables we eat is one of the simplest ways Australians can improve their health and wellbeing today as well as combat the growing rates of obesity and lifestyle diseases such as heart disease, Type 2 diabetes and a third of all cancers.
“Diets high in fruit and vegetables have been shown to improve psychological and physical markers of wellbeing. In particular, phytochemicals from fruit and vegetables reduce systemic inflammation which can lead to chronic disease.”
One of the key findings in the research is that a focus on variety could be the solution to boosting consumption.
People across Australia, in all occupations and weight ranges, were invited to participate in the online survey between May 2015 and October 2016. CSIRO researchers analysed this data to develop a comprehensive picture of the country’s fruit and vegetable consumption.
Chris Johnson
Evidence vapourised on e-cig safety
Insufficient evidence exists to support safety claims of electronic cigarettes, according to the National Health and Medical Research Council.
Chief Executive Officer Professor Anne Kelso has released a statement on the latest evidence for the safety, quality and efficacy of e-cigarettes, concluding that: “There is currently insufficient evidence to support claims that e-cigarettes are safe, and further research is required to enable the long-term safety, quality and efficacy of e-cigarettes to be assessed.”
E-cigarettes continue to be promoted as a safe alternative to conventional cigarettes, or as a quit smoking aid. But there is a lack of evidence to support these claims, Professor Kelso said.
While e-cigarettes may expose users to fewer toxic chemicals than conventional tobacco cigarettes, the extent to which this reduces harm to the user has not been determined.
There is also some evidence to suggest that e-cigarettes could act as a gateway to tobacco cigarettes for non-smokers.
“Until evidence of safety, quality and efficacy can be produced, health authorities and policymakers should continue to act to minimise harm to users and bystanders,” Professor Kelso said.
“This particularly applies to young people.”
NHMRC has provided close to $6.5 million for research into e-cigarettes since 2011. Outcomes from this research should be progressively available from June 2018.
Consumers are advised to seek further information about e-cigarettes from reliable sources, such as their State or Territory health department or local quit smoking service.
Chris Johnson
[Correspondence] Feedback of results to trial participants: be upfront or risk affront
We commend Erik Stenberg and colleagues for their well designed and delivered large randomised trial (April 2, p 1397),1 which investigated the utility of mesenteric defect closure in reducing the incidence of internal hernia after laparoscopic gastric bypass surgery. The study robustly answers the authors’ research question and a plenary audience at the European Obesity Summit in Gothenburg, Sweden, agreed almost unanimously that closure of mesenteric defects should now be standard practice.
[Correspondence] The need to revise the Helsinki Declaration
In 2011, The Lancet published an Article (Dec 10, p 1997)1 on the first case of a transplant using a synthetic trachea seeded with the patient’s own stem cells. The senior author was Paolo Macchiarini, a thoracic surgeon working at the Karolinska University Hospital, Stockholm. Macchiarini performed another three transplantations with the same technique at the Karolinska. Since research misconduct was suspected and several of the authors of the 2011 article retracted their authorships, The Lancet added an expression of concern to the article in April, 2016.