Telehealth could deliver massive savings: CSIRO

Using telehealth technology to help the chronically ill to monitor and manage their condition at home could almost halve mortality rates and save the health budget up to $3 billion a year, according to CSIRO researchers.

Announcing the results of a 12-month trial, the CSIRO team reported that chronically ill patients provided with a telehealth service in their home not only had reduced mortality, but had less need for medical care and experienced shorter stays in hospital.

The outcomes add to evidence of the potential for telehealth technology to significantly improve the lives of patients while at the same time reducing the cost of their care.

The trial involved 287 patients with an average age of 71 years, who had at least one chronic illness such as congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and coronary heart disease and had been hospitalised twice in the preceding year.

They were each provided with an internet-connected telemedicine device that could monitor vital signs including ECG, heart rate, lung function, blood pressure, oxygen saturation, weight and temperature as well as video conferencing and messaging capabilities.

Patients were asked take their measurements once a day.

Participants reported benefits including the early detection of potentially deadly heart problems, a sharp fall in the number of visits to the doctor, and greater understanding of their illness and how to manage it.

Lead researcher Dr Rajiv Jayasena said these improvements resulted in a 24 per cent saving on Medicare costs for participants, as well as a 36 per cent reduction in hospital visits, a 42 per cent drop in the length of hospital stays and a 40 per cent decline in the mortality rate.

Telehealth Nurse Coordinator at Djerriwarrh Health Services, Lay Yean Woo said the system allowed her to monitor her patients and detect any abnormalities from her office, saving time that can be spent seeing more patients.

“This technology as helped me as a nurse and this has made my time more efficient in the way I deliver my service,” Ms Woo said. “Also, with the time that has been freed up, I can look at more new clients being referred to me. At the end of the day I know they are better looked after.”

While older Australians have some health habits – only 7 per cent smoke and 41 per cent report undertaking regular physical activity – 70 per cent are overweight or obese, almost a third consider their health is poor or only fair, and 20 per cent have problems that severely or profoundly limit their mobility.

As life expectancy has increased, more patients are developing chronic and complex health problems. Caring for them is placing an increasing demand on the health system, and the pressure is likely to intensify as their numbers swell. Currently, around 15 per cent of the population is 65 years or older, but the Australian Institute of Health and Welfare estimates that proportion will reach 22 per cent by the middle of the century and 24 per cent by 2096.

Dr Jayasena said that, with older patients with multiple chronic diseases accounting for 70 per cent of health spending, these benefits had the potential to deliver significant savings to the health budget.

The CSIRO has calculated that if the telehealth service was rolled out to the half a million Australians it considers would be good candidates, the nation could save up to $3 billion a year on health costs.

“Our research showed that the return on investment of a telemonitoring initiative on a national scale would be in the order of five to one by reducing demand on hospital inpatient and outpatient services, reduced visits to GPs, reduced visits from community nurses and an overall reduced demand on increasingly scarce clinical resources,” Dr Jayasena said.

The CSIRO, through its Smart Safer Homes initiative, is also fitting homes with sensors that track patient movement and raise the alarm when something out of the ordinary, such as being still on the ground for a period of time, happens.

Adrian Rollins

Exploring transitions between drug treatment and homelessness in Australia

There is much research to suggest a considerable overlap between people experiencing precarious housing, and drug and alcohol misuse. Linking client data from specialist homelessness services and alcohol and other drug treatment services, this report provides a picture of the intersection of these two issues on a national scale. It reveals a vulnerable population, in which Indigenous Australians and experiences of domestic and family violence and mental health issues were all over-represented. Their poorer drug treatment and housing outcomes highlight the level of difficulty faced in assisting these people to achieve long-term outcomes.

Exploring drug treatment and homelessness in Australia: 1 July 2011 to 30 June 2014

[Series] Managing the public–private mix to achieve universal health coverage

The private sector has a large and growing role in health systems in low-income and middle-income countries. The goal of universal health coverage provides a renewed focus on taking a system perspective in designing policies to manage the private sector. This perspective requires choosing policies that will contribute to the performance of the system as a whole, rather than of any sector individually. Here we draw and extrapolate main messages from the papers in this Series and additional sources to inform policy and research agendas in the context of global and country level efforts to secure universal health coverage in low-income and middle-income countries.

Under the microscope

Hereditary blindness cured?

A Tasmanian-led research team has successfully altered eye tissue in a laboratory by replacing genes that cause blindness with normal genes.

The team used molecular gene shears deployed through a simple injection into the eye. The shears latched on to individual eye cells, chopped out DNA fragments containing rogue genes, and replaced them with normal genes.

Lead researcher Associate Professor Alex Hewitt, from the University of Tasmania’s Menzies Institute, said regulators would need to be satisfied that the technique was safe, and that the shears could be turned off once they had done their job before starting human trials.

Human medical trials are expected to commence in less than five years.

For more information visit http://www.menzies.utas.edu.au/home/nested-content/feature-large/our-research-is-leading-the-way-towards-prevention-and-better-treatment-of-inherited-eye-diseases

Low rates of cervical cancer screening

A report by the Australian Institute of Health and Welfare has found that only three in five eligible Australian women had a pap test in the past two years.

In 2013-2014, 3.8 million women aged 20 to 69 years (57 per cent) participated in cervical screening.

Despite the low participation rate, Australia’s cervical cancer rates are considered low by international standards.

In 2012, there were 725 new cases of cervical cancer diagnosed and in 2013 there were 149 deaths. This is equivalent to between nine and ten new cases of cervical cancer diagnosed per 100,000 women and two deaths from cervical cancer per 100,000 women.

For more information the report, Cervical screening in Australia 2013-2014, can be found at http://www.aihw.gov.au/publication-detail/?id=60129554885

Pain leading cause of severe behaviour in dementia

Existing or undiagnosed pain has been linked to severe behavioural symptoms associated with dementia, according to Australian researchers.

Associate Professor Stephen Macfarlane, Head of the Clinical Governance for the Dementia Centre for HammondCare, and his research team identified that in 65 per cent of cases, pain was the main contributing factor to severe behaviours in dementia patients. Other leading factors included environment (60 per cent), limited carer knowledge (38 per cent), and depression (21 per cent).

Associate Professor Macfarlane said that it was common to find that, instances where pain contributed to behaviours involving aggression, agitation, and anxiety for dementia patients, that once it was alleviated the intensity of such behaviours was significantly reduced.

“Pain is an enormous issue for people living with dementia, and for older people generally, and is often undiagnosed as a contributing factor to behaviours,” Associate Professor Macfarlane said.

For more information visit – http://www.hammond.com.au/news/pain-major-contributing-factor-for-severe-behaviours-in-dementia

Malaria’s weakness exploited

Australian National University researchers have found that changes in the protein that enables a malaria parasite to evade several anti-malaria drugs also make the parasite hyper-sensitive to other therapies – a weakness that could be exploited to cure the deadly disease.

The researchers said the findings could prolong the use of several anti-malarial drugs to treat the disease which kills 600,000 people around the world each year.

Lead researcher Dr Rowena Martin said the interactions of the modified protein with certain drugs were so intense that it was unable to effectively perform its normal role, which was essential to the parasite’s survival.

“Essentially, the parasite can’t have its cake and eat it too. So if an anti-malaria drug is paired with a drug that is super-active against the modified protein, no matter what the parasite tries to do it’s checkmate for malaria.”

The study was published in the PLOS Pathogens journal.

Whole-genome testing now available

Australia has its first clinical whole-genome sequencing service which could triple the diagnosis rates for Australians living with rare and genetic conditions.

The service was launched by the Garvan Institute of Medical Research’s Kinghorn Centre for Clinical Genomics. Director Professor John Mattick said the service marked a turning point in disease diagnosis and health care in Australia.

Patients seeking a diagnosis for a possible genetic condition will be referred to a clinical genetic service which will work with NSW Health Pathology to assess whether whole genome sequencing can provide an answer.

Those who may benefit will then be able to access the service, which will screen all 20,000 genes at one time.

The simple blood test costs $4300, and has the capacity to identify the biological cause of illnesses so rare only a handful of people have the condition worldwide.

For more information visit http://www.garvan.org.au/research/kinghorn-centre-for-clinical-genomics/clinical-genomics/sequencing-services

Kirsty Waterford

Member expertise informs AMA policy

One query often received in the secretariat of the AMA is about how AMA policy is formulated. This question has arisen recently following the change in the leadership of the AMA with the election of Dr Gannon as President and Dr Bartone as Vice President, prompting people to ask whether the leadership change affects AMA policies.

There is a substantial process to the development of AMA policy which evolves within the councils, committees and working groups of the AMA Federal Council, often in response to current issues.

The deliberations of the councils, committees and working groups are informed by background research and advice from the secretariat and, increasingly, from expert advice available from AMA members.

Under the AMA’s Constitution, the Federal Council is vested with responsibility for the organisation’s medico-political policy. It is the Position Statements and policies approved by Federal Council that inform the public comments of elected AMA leaders.

The work of Federal Council is far-reaching, covering policies as diverse as health financing and economics; medical workforce; medical practice; and training. This is in addition to the specific agendas of the five major councils of Federal Council.

The policy considerations reflect the objects of the AMA as set out in its Constitution – to look after the interests of the members of the AMA across all facets of their lives, to promote the wellbeing of patients, take an active part in the promotion of health care programs for the benefit of the community, and participate in the resolution of major social and community health issues.

The second objective, in particular, ensures that the AMA addresses many public health issues that affect patients and the communities in which they live.

Public health issues currently under review by working groups of Federal Council cover a wide range of subject areas including addiction, firearms, obesity, foetal alcohol syndrome disorder, blood borne viruses, and rheumatic heart disease.

The Position Statements that are developed by the working groups and finalised by Federal Council serve to inform members and the public at large, as well as to guide the AMA’s advocacy.

From time to time Federal Council also considers policies developed by the World Medical Association, of which the AMA is a member. WMA considers its policies at the twice-yearly meetings of its Council and annual meeting of its General Assembly.

Among current areas of work are consideration of medical tourism, the use of bio-banks, obesity in children, boxing, and medical cannabis.

The AMA draws on its own policies and Position Statements to inform its input into WMA policies.

With increased use of working groups, the Federal Council has been able to draw on the expertise of members who may not sit on the Council, but who have substantial specialised knowledge to contribute. Over coming months, members will be invited to indicate areas of special interest which will be recorded in the member database. This will assist to identify members with interests in specific areas of AMA advocacy for future communications.

How do you choose a leader (hint: it may not be what you think)

In 2016, women are less likely to be our leaders in the highest levels of medical education, hospital management and representation of the medical profession. This remains true even at the level of student leadership, despite a little over 50 per cent of medical students being female.

There are many societal reasons why women are underrepresented in leadership roles, such as absorbing a higher load of unpaid domestic work and a paucity of female leaders to model themselves after. There’s also something going wrong with the way that all of us – men and women alike – perceive our female leaders.

In choosing leaders and in judging their success, we all do our best to make the right decision. But our inherent biases have a nasty habit of getting in the way.

So how does gender impact the people we promote and the leaders we vote for? Research says ‘quite a lot’, and it starts long before we’re reading a person’s CV or hearing their election pitch. In spite of ourselves, the evidence shows that gender colours the way we view our day-to-day interactions.

Some examples? In an election scenario, a recording of a lower-pitched voice is perceived as more competent, stronger and more trustworthy than the same recording digitally manipulated to reflect a higher pitch. As such, the lower-pitched candidate was more likely to be chosen as leader by study participants. Our view of women, who on average have higher-pitched voices than men, is being formed the moment we hear them speak.

There are studies to show that women speak less than men in meetings, but are perceived to speak more. Another study that analysed the talking behaviour of US Senators found that when women did speak more than their share of the conversation, they were rated 14 per cent less competent by observers. Men who spoke more than their share were instead perceived as being 10 per cent more competent. So our female leaders walk the double bind of having less opportunity to demonstrate competency by contributing to discussion and decision, or instead speaking more and being viewed as less competent as a result.

When it comes to nominating for and receiving positions, both men and women are more likely to offer a job to a male candidate than to a female candidate with an identical CV. Additionally, if a fictitious advertisement for a leadership role is given to equally qualified men and women, women perceive themselves to be less suitable for the job than the men perceive themselves to be. So, women are less likely to put themselves forward for a leadership position than men, and we’re all less likely to believe a women who does put herself forward should be given the role.

However, many of these effects can be reversed where an effort is made to do so. For example, the same study that identified a gender disparity in the amount of time speaking at meetings also found that when a decision was being made by unanimous vote rather than majority rule the effect disappeared, and female voices were equally heard. Additionally, while research shows that the characteristics typically associated with leadership are stereotypically masculine, it also shows that this effect is decreasing over time, and suggests flatter organisational hierarchies which promote teamwork and interaction as the cause.

When we find ourselves forming an opinion about a male leader, or a female one, we owe it to them to think about why. To reflect on which judgements are valid, and which are instead the result of seeing a majority of leaders look a particular type of way. Only once we’ve understood our biases can we set about changing them.

All of us are responsible for the promotion and election of our leaders; within medical education, within hospital management, and as our professions’ representatives. And we need to get those decisions right.

[Correspondence] Increasing value and reducing waste in biomedical research

The challenges to biomedical research posed by the 2014 Lancet Series “Research: increasing value, reducing waste”, and renewed by David Moher and colleagues1 (April 9, p 1573), are daunting and rigorous. The recommendations are costly, and so the efficiencies need to outweigh them. Here, I wish to comment on three of the issues: the goal, the costs, and the causes of inefficiency, particularly in publication.

[Correspondence] The benefits of screening–and its harms

In response to our Viewpoint (Jan 16, pp 308–10) about screening for abdominal aortic aneurysms,1 Kosmas Paraskevas and colleagues (April 16, pp 1617–18)2 mention only the benefit (a diagnosis-specific mortality reduction) and ignore its harms. This is insufficient when one considers and compares screening programmes, which is indeed the central message of our Viewpoint.1 The research community commonly exhibit a strong focus on benefits of interventions, including screening, whereas important harms are not quantified—ie, in randomised trials.

[Correspondence] The first recorded use of microscopy in medicine: Pope Innocent XII’s autopsy report

In the history of medicine, the discovery and the use of the microscope in clinical practice and biomedical research was a revolutionary achievement. The cultural shift from the traditional macroscopic necroscopy to a microscopic and ultrastructural perspective was essential for the development of modern pathology and for recognising physiopathological mechanisms of several diseases. Physicians started to use the microscope during the 17th century, but they initially limited its use to anatomical, and not pathological, studies.