more_vertRichard Horton’s Offline Comment1 (Sept 10, p 1040) refers to the paper we published in The BMJ2 as “disputed research and tendentious opinions about statin use among people at low risk of cardiovascular disease”, but fails to report that the primary analysis and conclusion in our article have not been disputed. Rather, the conclusion of the 2012 Cholesterol Treatment Trialists (CTT) meta-analysis3 that “In individuals with 5-year risk of major vascular events lower than 10%, each 1 mmol/L reduction in LDL cholesterol produced an absolute reduction in major vascular events of about 11 per 1000 over 5 years” is what is disputed.
Preference: Statistics, epidemiology and research design
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[Series] Uses of polypills for cardiovascular disease and evidence to date
Polypills have been approved in more than 30 countries, but worldwide experience with and availability of polypills remain limited, unlike fixed-dose combinations in other diseases such as HIV, tuberculosis, and malaria. In this Series review, we aim to propose a guide for the use of polypills in future research and clinical activities and to synthesise contemporary evidence supporting the use of polypills for prevention of atherosclerosis. Polypill uses can be categorised by population and indication, both of which influence the balance between benefits and risks.
[World Report] Profile: Centre for Clinical Brain Sciences, Edinburgh, UK
The Centre for Clinical Brain Sciences (CCBS) at the University of Edinburgh, UK, is strategically located at four hospital sites across the Scottish capital and has three research divisions—Clinical Neurosciences, Neuroimaging Sciences, and Psychiatry—each with its own research director. CCBS was formed during what current centre and Clinical Neurosciences director, Siddharthan Chandran, describes as “a bonfire of departments” in 2004 to drive a new interdisciplinary approach to the understanding and treatment of major brain disorders.
[Correspondence] What are funders doing to minimise waste in research?
The Lancet’s Series on reducing waste and increasing value in medical research was published in 2014. Subsequently, developments consistent with the recommendations made in the Series were documented in an article based on informal enquiries made of research funders and regulators, researchers and research institutions, and journal editors. We have explored in greater detail how the most influential of these actors in the research community, the research funders, monitor and take steps to reduce waste in the research they support; and how they support methodology research and research infrastructure needed to show how waste can be reduced.
News briefs
Gene linked to “Rain man” brain disorder
Murdoch Childrens Research Institute (MCRI) researchers have discovered a new gene linked to a congenital brain abnormality experienced by the person who inspired the movie Rain Man. Associate Professors Paul Lockhart and Rick Leventer led an international team which has discovered the first gene, called Deleted in Colorectal Cancer (DCC), known to cause the loss of the main connection between the two halves of the brain, in the absence of any other syndromes linked to the condition. About one in 4000 babies are born with agenesis of the corpus callosum (ACC). Symptoms of ACC, where the corpus callosum is missing, are varied but can include intellectual disability, autism and cerebral palsy. Individuals with ACC who also have the DCC gene change often struggle with “mirror movements”. This means if they move one hand, the other hand automatically moves in the same way. This causes problems with everyday tasks including eating, washing the dishes, writing, driving a car and using a mobile phone or tablet. Lockhart and Leventer’s study suggests that individuals with ACC caused by mutations in this gene have much better neurodevelopmental outcomes than people with ACC linked to a particular syndrome. This holds important implications for decision making if the condition is detected during prenatal testing, they wrote. “The results of this research will provide better information to parents regarding potential outcomes for their children, helping to make more informed reproductive decisions,” Lockhart said. “Our research also provides important new information about how nerves connect to the appropriate part of the brain during development of the embryo. This has potential implications for our understanding of a broad range of neurodevelopmental conditions such as autism spectrum disorder. This gene is playing a role in how nerves connect with each other and transfer information. Deficits or problems in this process are emerging as associated with autism spectrum disorder.” The finding was published in Nature Genetics.
http://dx.doi.org/10.1038/ng.3794
Life expectancy booming
By 2030 there is a greater than 95% probability that life expectancy at birth among Australian men will surpass 80 years, and a greater than 27% probability that it will surpass 85 years, according to research published in The Lancet. Researchers from Imperial College London and other international sites, developed 21 forecasting models, then applied the approach to project age-specific mortality to 2030 in 35 industrialised countries with high quality vital statistics data. They used age-specific death rates to calculate life expectancy at birth and at age 65 years, and probability of dying before age 70 years. The increase in life expectancy will be largest in South Korea, some western European countries and some emerging economies. South Korean women are predicted to live beyond 86 years by 2030, with a 57% probability that their life expectancy will be beyond 90 years. The smallest increases will be in the USA, Japan, Sweden, Greece, Macedonia, and Serbia. “Countries with high projected life expectancy are benefiting from one or more major public health and health-care successes. Examples include high-quality healthcare that improves prevention and prognosis of cardiovascular diseases and cancers, very low infant mortality, low rates of road traffic injuries and smoking (Australia, Canada, and New Zealand), and low body-mass index (French and Swiss women) and blood pressure (Canada and Australia).”
Council of Private Specialist Practice created to respond to challenges
ASSOCIATE PROFESSOR JULIAN RAIT
The Council of Private Specialist Practice (CPSP) is the most recent of the Federal AMA’s Councils – created in 2016 to recognise and respond to the key challenges that face private practitioners within the Australian health system. Our Terms of Reference provide for us to identify issues relating to private specialist medical practice and make recommendations to Federal Council, as well as develop and draft policy or position papers on key topics.
Private practices are an essential component of a sustainable Australian health system. The private system alleviates much of the demand on the public system – providing nearly 70 per cent of all elective surgical admissions.
And as with all other advanced economies, Australia requires both a strong private and public health system to meet the challenges that lie ahead – including an ageing population, rising health care costs and increasingly complex care.
The structure and format of private specialist practice is also changing – with solo and group practices competing with corporate entities.
Two big “funders” of private health, the Commonwealth Government via the MBS, and the Private Health Insurers, continue to grapple with how best to fund the system in an era of escalating cost pressures. In response, they are seeking to drive down their costs, especially by curbing the growth in their outlays. This creates significant pressure on the private medical practitioner who is trying to deliver a high quality and economically viable service. Consequently, patients are incurring escalating out-of-pocket costs, prompting many to question the value of their private health insurance.
Private health is an area currently under extensive review, and subject to increasing scrutiny. We’ve seen the previous Health Minister announce the Private Health Ministerial Advisory Committee (PHMAC), and under this committee, a further number of working groups.
CPSP has been engaged, and supportive of the AMA’s work in relation to PHMAC’s deliberations– which clearly indicate that our Federal Government is considering various options in an attempt to make private health insurance a more attractive proposition for Australians. This includes considering clear categories of health insurance, reviewing of hospital contracting arrangements (and especially second tier funding provisions), while making polices easier to understand and removing impediments to policy portability for customers.
The reality is that a great deal of discussion will arise from the usual hot button media issues – with constraints on out-of-pocket costs and online rating sites being hailed as the ‘answer’ to make private health insurance “more attractive”. Meanwhile, health insurers continue to record extraordinary profits and breathtaking returns on equity. For example, news outlets are reporting NIB recently received approval to lift its premiums by 4.48 per cent after announcing a 65 per cent increase in net profit (compared to the prior year) and scoring a return on equity of 32 per cent – with the latter result being double that of the Commonwealth Bank.
The CPSP has, and will continue to, be firm advocates for the profession on these issues. A little known fact among the broader population is that medical fees only account for 16 per cent of private health insurance benefits with 85.6 per cent of medical services having no gap, and 92.3 per cent of services having nil or a known gap charge[1]. So you might agree that the gap fees of medical practitioners are not the leading cause of the PHI affordability challenge.
However, despite these modest figures, there is a perception that out-of-pocket costs are not being actively managed by the profession – a view apparently held by governments, consumers and mass media. The profession can no longer ignore the issue around significant or unexpected out-of-pocket costs without it being seen as a failure of the profession to self-regulate appropriately, and become the scapegoat for all the affordability problems of the system. Insurers and consumer groups have commenced research on the quantum and frequency patients experience these costs.
Moving beyond private health insurance reforms, we’ve also seen the Federal Government embark on changes to the medical indemnity insurance subsidy schemes. Many doctors would be aware that last year the Government included a funding cut of $36 million to one of these long-standing subsidies that underpin medical indemnity insurance in the Mid-Year Economic and Fiscal Outlook (MYEFO). Furthermore, they have announced a review into all the Government’s indemnity support schemes – signalling that strong consideration is being given to future cuts to these important Government subsidies for the profession.
To that end, CPSP will be closely monitoring any proposed changes and the AMA will be participating in the forthcoming review.
The AMA has already written to the Government, reminding them of the truly disruptive crisis that brought about the current support schemes, and warning that any changes made without effective consultation with the profession, and their indemnity insurers, could lead to significant unintended consequences. CPSP has also discussed the importance of universal coverage arrangements (whereby no registered doctor can be denied insurance) – agreeing that any changes here need to be carefully considered.
Finally, there continues to be a number of reviews underway which may have impacts upon private practice. The Senate Community Affairs Committee has an inquiry into Prosthesis List Framework, the Australian Competition and Consumer Commission is calling for submissions on their annual report to the Senate on Private Health Insurance, and of course the MBS Review Taskforce continues. CPSP will be navigating all these reviews, ensuring that the private practitioner’s voice continues to be well placed to advise the AMA on the implications of any changes.
The coming weeks will also see the release of the AMA’s Private Health Insurance Report Card – a good chance to shine a light on the key issues facing private health, so please continue to be attentive to our initiatives.
[1] Australian Prudential Regulation Authority (APRA). Private Health Insurance Quarterly Statistics. December 2016 (Released 14 February 2017).
Public hospitals – funding needed, not competition
ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, AMA HEALTH FINANCING AND ECONOMICS COMMITTEE
Under its terms of reference, public hospital funding is a key focus for Health Financing and Economics’ work. How funding arrangements affect the operation of public hospitals and their broader implications for the health system has always been an important consideration for HFE, and for Federal Council and the AMA overall.
The AMA Public Hospital Report Card is one of the most important and visible products for AMA advocacy in relation to public hospitals.
The 2017 Report Card was released by the AMA President on 17 February 2017. The launch and the Report Card received extensive media coverage.
The Report Card shows that, against key measures relating to bed numbers, and to emergency department and elective surgery waiting times and treatment times, the performance of our public hospitals is virtually stagnant, or even declining.
Inadequate and uncertain Commonwealth funding is choking public hospitals and their capacity to provide essential services.
The Commonwealth announced additional funding for public hospitals at the Council of Australian Governments (COAG) meeting in in April 2016. The additional funding of $2.9 billion over three years is welcome, but inadequate.
As the Report Card and the AMA President made very clear, public hospitals require sufficient and certain funding to deliver essential services.
“Sufficient and certain” funding is also the key point in the AMA’s submission to the Productivity Commission’s inquiry into Reforms to Human Services, in relation to public hospitals. The Commission is expected to report in October 2017.
As part of this inquiry, the Productivity Commission published an Issues Paper seeking views on how outcomes could be improved through greater competition, contestability and informed user choice.
While the AMA believes there is clearly potential to improve outcomes of public hospital services, its submission highlighted that there are significant characteristics of Australia’s public hospitals that must be taken into account.
Health care is not simply a “product” in the same sense as some other goods and services. Public hospitals are not the same as a business entity that has full or even substantial autonomy over their customers and other inputs, processes, outputs, quality attributes, and outcomes.
Public hospitals work on a waiting list basis, usually defined by acuity of need, to manage demand for public hospital services. Private hospital services typically use price signals. There is limited scope to apply mechanisms for patient choice (such as choice of treating doctor) to access arrangements in public hospitals that are governed by waiting lists.
Public hospitals also operate within a highly developed framework of industrial entitlements for medical practitioners and other staff that are tightly integrated with State/Territory employment awards. These measures are intended to encourage recruitment and retention of medical practitioners to the public sector, offering stable employment conditions, continuity of service and portability of entitlements. They support teaching, training and research in the public sector as well as service delivery.
The freedom to choose between public and private hospital care, and the degree of choice available to patients in public hospitals as distinct from private patients, is an integral part of maintaining Australia’s balanced health care system. The broad distinction between public and private health care is generally understood by the community as a basic feature of the health system and part of Medicare arrangements, even though detailed understanding of how this operates, including what they are actually covered for in specific situations, is often lacking for many people.
Introducing private choice and competition elements into public hospital care will tend to blur the distinction between public and private health care, and reduce the perceived value of choice as a key part of the incentive framework for people choosing private health care.
The Commission’s Issues Paper proposes that increased competition will address equitable access for groups including in remote areas, benchmarking and matching of best practice, and greater accountability for performance. These are all worthwhile and important objectives in their own right. As such, they are already the focus of a range of initiatives.
Public hospitals are already subject to policies and requirements that address the same ends of improved efficiency, effectiveness and patient outcomes, including:
- Hospital pricing, now supported by a comprehensive, rigorous framework of activity based funding and the National Efficient Price;
- Safety and quality, supported by continuously developing standards, guidelines and reporting, including current initiatives to incorporate into pricing mechanisms;
- Improved data collection and feedback on performance including support for peer-based comparison.
The single biggest factor that will increase the returns from such initiatives is the provision of sufficient and certain funding. Increased competition, contestability and user choice will not address this need.
The AMA Public Hospital Report Card 2017 is at ama-public-hospital-report-card-2017
“London to Sydney – by any means”
BY DR CLIVE FRASER
The 1968 London to Sydney Marathon
It’s been almost 50 years since an adventurous group of drivers in 98 cars set off from London on a long road race to the Antipodes (aka Sydney) on the other side of the world.
The idea for the race came from the owner of the Daily Express newspaper, who reasoned that the stagnant UK economy could be bolstered by the world-wide attention that the race would create.
He put up £10,000 in prize money and off they went.
The rules were simple. Go as fast as possible and try to get to Sydney first.
Repairs could be undertaken en route, but no one was allowed to touch their vehicle whenever it was being transported by boat.
The field was made up of a range of vehicles from Hillman Hunters to Falcon GTs and the drivers were as diverse as privateers and seasoned rally drivers such as Andrew Cowan.
I was 10 years old when the race was run and I recall being mesmerized as I followed the field across the globe.
After all, this was all before Apollo 11 and man setting foot on the Moon.
There were still remote places on Earth and National Geographic maps were still being used for navigation.
Unbeknown to me, a family from Australia were making the same trip from London to Sydney in a recently purchased Kombi van.
Their route would be more circuitous taking them first to Norway, across Scandinavia and down through Europe into Spain.
From there they were finally heading in an Easterly direction towards the Middle East and onwards.
I recently met the driver who is not far off becoming a Centenarian.
He has so many stories to tell and I had so many questions to ask.
For starters, “Did the Kombi break down?”
The answer being, “No, never.”
“Did you have any dramas on the trip?”
The answer being, “Only in Afghanistan!”
No surprises there I thought, after all even today Afghanistan is still a remote and dangerous place.
“Oh no, not at all,” I was told.
“We’d camped for the night in a field. We were just about asleep when there was a knock on the window. It was a police officer. He told us that there’d been some problems between a local tribe and another traveller recently. He thought it would be safer if we camped in the police station compound, which we did.”
“What was the highlight of the trip?” I asked.
“The roads, how great the roads were, in … in Afghanistan,” came the reply.
I thought I’d misheard the last sentence.
Afghanistan and great roads, could that be possible?
Well, yes.
Between 1960 and 1967 the US Army Corp of Engineers built 2,700 miles of paved highways in Afghanistan.
According to my research, the purpose of the regional transportation project was peaceful with no mention of the politics of the Cold War and the northern Russian neighbours.
The construction of just one highway between Kabul and Kandahar would shorten the journey from 10 days to six hours.
I’m not sure how many of the 50-year-old highways still remain, but since November 2016 they are being re-built again with the US stating that: “The most effective weapon America possesses in the war on terrorism may not be its military capacity, but rather rural roads and access to technology.”
Andrew Cowan won the London to Sydney Marathon in a Hillman Hunter and that model continued production in Iran until 2005.
My almost Centenarian friend also got to Sydney and is still running his marathon.
Safe motoring,
Doctor Clive Fraser
[World Report] Scholarship fund for young African scientists facing demise
A UK-Japanese scholarship for young African researchers, which has been running since 2008, will end this year if new sources of funding are not forthcoming. Geoff Watts reports.
New study debunks crazy cat lady theory
In good news for single women everywhere, a new study has cleared cats of causing mental illness.
Cats came under the microscope after a number of scientific studies linked Toxoplasma Gondii (T. Gondii) infection with mental health issues, including schizophrenia, suicide and intermittent rage disorder.
Cats carry T. Gondii, prompting speculation that cat ownership may put people at increased risk of mental illness, by exposing them to it.
“However, only a handful of small studies have found evidence to support a link between owning a cat and psychotic disorders, such as schizophrenia,” researchers Francesca Solmi and James Kirkbride, from University College London, wrote for The Conversation UK.
“And most of these investigations have serious limitations. For instance, they relied on small samples, did not specify how participants were selected, and did not appropriately account for the presence of missing data and alternative explanations. This can often lead to results that are born out of chance or are biased.”
To further investigate, Ms Solmi and Dr Kirkbride conducted a study using data from approximately 5,000 children who took part in the Avon Longitudinal Study of Parents and Children between 1991 and 1992, and have been regularly followed up for further health information.
“So, unlike previous studies, we were able to follow people over time, from birth to late adolescence, and address a number of the limitations of previous research, including controlling for alternative explanations (such as income, occupation, ethnicity, other pet ownership and over-crowding) and taking into account missing data,” Ms Solmi and Dr Kirkbride wrote.
They studied whether mothers who owned a cat while pregnant; when the child was four years old; and 10 years old, were more likely to have children who reported psychotic symptoms, such as paranoia or hallucinations, at age 13 and 18 years of age.
“So are cats bad for your mental health? Probably, not,” they concluded.
“We found that children who were born and raised in households that included cats at any time period – that is, pregnancy, early and late childhood – were not at a higher risk of having psychotic symptoms when they were 13 or 18 years old.
“This finding in a large, representative sample did not change when we used statistical techniques to account for missing data and alternative explanations. This means that it is unlikely that our results are explained by chance or are biased.”
However, there is evidence linking exposure to T. Gondii in pregnancy to a risk of miscarriage and stillbirth, or health problems in the baby.
“In our study, we could not directly measure exposure to T. Gondii, so we recommend that pregnant women should continue to avoid handling soiled cat litter and other sources of T. Gondii infection, such as raw or undercooked meats, or unwashed fruit and vegetables,” they said.
“That said, data from our study suggests that owning a cat during pregnancy or in early childhood does not pose a direct risk for offspring having psychotic symptoms later in life.”
The study did not investigate why apparently perfectly normal adults can suddenly change behaviours after acquiring a kitten or cat, such as posting endless photos and videos on social media sites, talking about “kittehz” and “hoomans”, and taking their unimpressed companion animals for photos with Santa.
Maria Hawthorne
(*disclosure – the author has two cats…. but the Editor is a dog person and insists no such study necessary for dog owners.)