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Preference: Statistics, epidemiology and research design

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Managing elderly diabetes no simple task

Most elderly diabetics are prescribed glucose-lowering medications, and only one in five use insulin to manage their diabetes, according to a report by the Australian Institute of Health and Welfare.

Highlighting the complexity of treating type 2 diabetes in older patients, the AIHW used linked data from the Pharmaceutical Benefits Scheme and the National Diabetes Services Scheme (NDSS) to show that while most (85 per cent) of patients 65 years and older were on glucose lowering medications, just 40 per cent used a single medication. One in five used two glucose lowering therapies simultaneously, and 11 per cent were on triple therapies.

In addition, 77 per cent were also using agents to lower their blood pressure, 74 per cent were using drugs to modify lipids (68 per cent were using both), 24 per cent were being supplied with anti-depressants, 20 per cent were using insulin and 4 per cent were on anti-psychotics.

Generally, the authors of the report said, the longer since type 2 diabetes was diagnosed, the more likely it was that a patient would be prescribed with all medicine types, and the more intensive (dual or triple therapy) their glucose lowering treatment regimens would be.

Increasingly, type 2 diabetes in older patients is being treated with drugs rather than diet and exercise alone.

This was significant, the authors said, because the high prevalence of co-morbidities in such patients made the balance of risks and benefits in using medicines a finely-tuned calculation.

The release of the report coincides with changes to the NDSS that came into effect on 1 July.

Under the changes, people with diabetes can continue to access NDSS products such as needles, syringes, blood glucose test strips and urine test strips from NDSS community pharmacies, but can no longer access the products from Diabetes Australia or local state and territory diabetes organisations.

In addition, people with type 2 diabetes not using insulin will receive an initial six month supply of subsidised blood glucose test strips under the NDSS. After six months, they will only be eligible for further access to subsidised test strips if their doctor or other authorised health professional considers it clinically necessary to use test strips.

The change follows advice from the Pharmaceutical Benefits Advisory Committee which recommended restrictions to access blood glucose test strips based on research which found there was limited evidence that self-monitoring of blood glucose improved blood glucose control, quality of life or long term complications in people with type 2 diabetes who are not using insulin.

Patients with diabetes using insulin or women with gestational diabetes will not be affected by these changes.

The restrictions will come into effect six months from the date of a NDSS Registrant’s first test strip purchase.

There is no limit on the number of extensions to access that may be obtained from an authorised health professional while there is a continuing clinical need.

For more information about the changes visit https://www.ndss.com.au/important-changes-to-the-ndss

The AIHW report can be found at http://www.aihw.gov.au/publication-detail/?id=60129555607

Kirsty Waterford

 

The opportunities of the new Australian Parliament

The composition of the new Federal Parliament provides excellent opportunities for the development of a health policy for Australia. 

This is because the many points of view that need to be reconciled to achieve a comprehensive and inclusive policy will be represented in the new parliamentary configuration. While this may at first sight seem clumsy and inefficient, it is a process critical to developing a policy that will guide health service provision and financing on behalf of the community.  As the Canadian commentator John Ralston Saul has written, the price of democracy is inefficient conversations – lots of them – that allow for all voices to be heard.

There is a further reason to be pleased that in the new arrangements a more cautious, inclusive and conversational approach will be applied to the development of a national health policy. It is that all too often, insufficient consideration is given to the unintended side effects of what appear to be bright new policy initiatives. 

Amartya Sen, a Nobel Prize winning Indian philosopher and economist, refers to this omission as one of the more common cardinal errors of social policy makers.  If asked, all the players may be able to provide more insights than one thinking alone. 

Simply having many players at the policy table does not, of course, guarantee freedom from this error.  As the Chilcot Report on the United Kingdom’s involvement in the recent Iraq war points out, a ‘coalition of the willing’ failed to question in depth what the consequences of war would be in the longer term. It was as though the policy stopped halfway.

The unintended side effects of the (good) policy to fund clinical psychologists to assist with the management of patients with mental health problems via general practice – workforce redistribution and budget over-runs – are examples of side effects that may have  been anticipated if more ‘thought experiments’ – thinking through what might follow – had been conducted prior to implementation.

By what process might this policy be developed? 

First, parliamentary leadership is required. A policy development oversight group that is genuinely multi-partisan should be established. This is not a matter of setting up yet another expert committee or commission of advice. The politicians need to lead. How the group wishes to proceed is, of course, entirely up to them.

Second, it is critical that high on the group’s agenda be a discussion about what Australia may reasonably expect from its health services, private and public, hospital and community, curative and preventive. There must be limits: what are they? How far do we wish to go in ensuring equity of access? How far in privatising the costs of health care? This is a special problem for patients who have serious and continuing complex problems, as my colleagues and I and many others have documented. Chronic illness is a fast track to poverty at present.

There are many topics to be discussed – which underlines my argument in favour of an inclusive conversation, auspiced by the Parliament, to begin. Attitudes vary in relation to prevention, and in the last Parliament a national agency for prevention was abolished. Is that what we want to do, or the best we can do?

And what are our expectations of research as a society? We know what experts and academics expect, but there are other voices as well that need to be heard, including those of some who have values espoused by science (and some who don’t).

Finally, there are ways of doing policy development well. From my personal perspective, I place a high premium on the contribution that solid data can make to the process. But my experience with policy development leaves me in no doubt that the ‘voice’ of data is but one voice. For a policy to work, data elegance is not enough. There must be buy-in from those whose lives and livelihoods are affected by it.

The new parliamentary structure requires a more humble and inclusive approach to policy formation.  Nowhere is this of more value than in working out where we as a nation are going with health and health care.

Focus on rheumatic heart disease

 As the new President of the AMA I will, like my predecessors, chair the AMA’s Taskforce on Indigenous health. This recognises and emphasises the importance of the AMA’s efforts to improve the health and wellbeing of Aboriginal and Torres Strait Islander people, and our desire to keep ‘Closing the Gap’ initiatives at the top of our agenda.

The Taskforce, which was established in 2000, is comprised of representatives of the AMA Federal Council, AMA members and Indigenous health groups, including the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors’ Association (AIDA).

The Taskforce is a robust and dedicated entity which identifies, develops and recommends Indigenous health policy and strategies for the AMA and oversees the AMA’s annual Report Card on Indigenous Health.

This year, the 2016 Report Card on Indigenous Health will focus on rheumatic heart disease (RHD) – a major preventive health issue that significantly affects Indigenous people, particularly those in remote areas. As AMA WA President, I supported legislative change to improve reporting and reduce the burden of disease in Aboriginal communities in Western Australia.

RHD is a classic example of the many preventable chronic diseases that are largely responsible for the health gap between Indigenous and non-Indigenous people, with its burden largely extinguished in other parts of the Australian community. We can no longer allow the prevalence of chronic diseases like RHD to remain unaddressed.

The 2016 Federal election provided an opportunity for the AMA to present all political parties and candidates with the issues that the AMA sees as vital in meeting the challenge of closing the health gap.

While we have seen some recent improvements in Indigenous health, particularly in reducing infant mortality and smoking rates, the AMA wants to see the Commonwealth commit to improving resourcing for culturally appropriate primary health care for Aboriginal and Torres Strait Islander people.

The AMA has repeatedly said that it is not credible that Australia, one of the world’s wealthiest nations, cannot address the health and social justice issues that affect 3 per cent of its citizens. We say this again. The fact that it is our nation’s first people makes it an even greater moral imperative.

With the re-election of the Turnbull Government, the AMA will continue its call for long-term funding and commitments to Indigenous health. We will work closely with key ministers, government departments and other key stakeholders to ensure that appropriate action is taken.

As outlined in its Key Election Issues statement, the AMA urges the Federal Government to:

  • correct the under-funding of Aboriginal and Torres Strait Islander health services;
  • establish new, or strengthen existing, programs to address preventable health conditions that are known to have a significant impact on the health of Aboriginal and Torres Strait Islander people, such as cardiovascular disease (including rheumatic fever and rheumatic heart disease), diabetes, kidney disease, and blindness;
  • increase investment in Aboriginal and Torres Strait Islander community-controlled health organisations. Such investment must support services to build their capacity and be sustainable over the long term;
  • develop systemic linkages between Aboriginal and Torres Strait Islander community-controlled health organisations and mainstream health services to ensure high quality and culturally safe continuity of care;
  • identify areas of poor health and inadequate services for Aboriginal and Torres Strait Islander people and direct funding according to need;
  • institute funded, national training programs to support more Aboriginal and Torres Strait Islander people become health professionals to address the shortfall of Indigenous people in the health workforce;
  • implement measures to increase Aboriginal and Torres Strait Islander people’s access to primary health care and medical specialist services;
  • adopt a justice reinvestment approach to health by funding services to divert Aboriginal and Torres Strait Islander people from prison, given the strong link between health and incarceration;
  • increase funding for family violence and frontline legal services for Aboriginal and Torres Strait Islander people;
  • appropriately resource the National Aboriginal and Torres Strait Islander Health Plan to ensure that actions are met within specified timeframes; and
  • support the establishment of a Central Australia Advanced Health Research and Translation Centre. Central Australia faces many unique and complex health issues that require specific research, training and clinical practice to properly manage and treat and this type of collaborative medical and academic research, along with project delivery and working in remote communities, is desperately needed.

 Closing the gap in health and life expectancy between Indigenous and non-Indigenous people is an achievable task – it is also an agreed national priority.

The Federal Government must build on existing platforms and ramp up its ambitions to achieve health equality for Aboriginal and Torres Strait Islander people. Without commitment and action from our national leaders, the gap will remain wide and intractable. The Taskforce will inform the AMA’s advocacy in ensuring that this does not remain the case.

 

News briefs

Unnecessary EOL treatment widespread

University of New South Wales reviewers, reporting in the International Journal for Quality in Health Care, have found that more than a third of elderly patients hospitalised at the end of their life received “invasive and potentially harmful medical treatments”. The analysis of 38 studies over 2 decades, based on data from 1.2 million patients, bereaved relatives and clinicians in 10 countries including Australia, found that the practice of doctors initiating excessive medical or surgical treatment on elderly patients in the last 6 months of their life continues in hospitals worldwide. Dr Magnolia Cardona-Morrell, who led the research at UNSW’s Simpson Centre for Health Services Research, said rapid advances in medical technology have fuelled unrealistic community expectations of the healing power of hospital doctors and their ability to ensure patients’ survival. “It is not unusual for family members to refuse to accept the fact that their loved one is naturally dying of old age and its associated complications and so they pressure doctors to attempt heroic interventions,” Dr Cardona-Morrell said. “Doctors also struggle with the uncertainty of the duration of the dying trajectory and are torn by the ethical dilemma of delivering what they were trained to do, save lives, versus respecting the patient’s right to die with dignity.” The study revealed 33% of elderly patients with advanced, irreversible chronic conditions were given non-beneficial interventions such as admission to intensive care or chemotherapy in the last two weeks of life while others who had not-for-resuscitation orders were still given CPR. The researchers also found evidence of invasive procedures, unnecessary imaging and blood tests, intensive cardiac monitoring and concurrent treatment of other multiple acute conditions with complex medications that made little or no difference to the outcome, but which could prevent a comfortable death for patients.

Breast cancer treatment impacts independent living

Researchers from the US have found one in five women undergoing breast cancer treatment for a year became “incapable of performing some of the basic tasks required for independent living”. Published in Cancer, the study also found that a simple survey can help identify which women are at risk of such functional decline. Cynthia Owusu from Case Western Reserve University in Cleveland, Ohio, and her colleagues studied a group of 184 women aged 65 years and older who had been recently diagnosed with stage I to III breast cancer. The researchers used the Vulnerable Elders Survey, a 13-item self-administered tool that has been validated in community-dwelling elders to predict functional decline or death within 12 months. Patients completed the survey just prior to breast cancer treatment. Within 12 months, 34 of the 184 patients developed functional decline and seven died. The risk of functional decline or death rose with increasing survey scores. Women without an education beyond high school were disproportionately affected. “Our findings are important because the study validates the Vulnerable Elders Survey as a useful tool for identifying older women with breast cancer who may be at increased risk for functional decline within a year of treatment initiation,” she said. “This instrument offers the opportunity for early identification and will inform the development of interventions to prevent and address functional decline for those particularly at risk, such as women with low socioeconomic status.”

[Perspectives] Julie Makani: at the cutting edge of sickle-cell disease

A passion for science is not unusual among medical researchers; rather less common is the capacity to step back from the seductive pleasures of discovery and take a more strategic view of what you’re about. Julie Makani has spent a decade and half in the Department of Haematology and Blood Transfusion at Tanzania’s Muhimbili University of Health and Allied Sciences in Dar es Salaam. During this time she has shown how choosing the right strategy can foster the kind of invigorating purpose that now underpins her department’s programme of work on sickle-cell disease.

[Comment] The Wakley Prize, 2016: take us on a journey

The Lancet invites you to take a little time away from preparing for your clinical work, research, medical studies, consultations, or grant proposal and instead write an essay about what most concerns you in health care. The Wakley Prize is The Lancet’s annual essay competition. The prize will be awarded to the best essay on any topic of importance to medicine and the competition is open to anyone working in a health-related field. We expect fine writing, originality, and thought-provoking argument—and for you to engage our hearts and our minds.

Nation’s health only partly on track

Australia is making progress in reducing rates of smoking and dangerous drinking but is losing the battle to rein in weight gain, high blood pressure, and salt and sugar consumption, according to a national snapshot of health trends.

Australia’s Health Tracker, produced by the Australian Health Policy Collaboration with the support of 50 public health organisations, shows that the nation is making good progress toward reducing drinking and smoking, with the proportion of adults drinking at risky levels trending down toward 18 per cent and the country on track to cut the number of adults who strike up on a daily basis down to 10.6 per cent by 2025.

But adults and children are continuing to put on weight, eating too much sugar (and salt) and not doing enough exercise, according to the tracker.

It shows that more than 63 per cent of adults are overweight or obese, along with more than a quarter of children, and almost a half of adults and 70 per cent of children are eating too much sugar.

The tracker found that people are not doing enough exercise, particularly in light of their energy-rich diets – just 55 per cent of adults and less than 10 per cent of teens meet physical activity recommendations.

These readings underline concerns that not enough is being done to reduce the incidence of chronic disease by changing behaviour and encouraging healthier lifestyles.

According to the authors of the Health Tracker, 50 per cent of Australians have a chronic disease, and they estimate that almost a third of such illnesses could be prevented by eliminating smoking, losing weight, cutting down on drinking, taking exercise and reducing blood pressure.

“Chronic disease is the biggest health challenge of the twenty-first century,” the authors said. “Australia lags well behind comparable countries in tackling the risk factors for preventable chronic diseases.”

But, they said, “much of Australia’s chronic disease burden is preventable or capable of significant amelioration”, and urged that there be “population-level interventions that target risk factors shared by many population groups and communities”.

There have been concerns that preventive health has been undermined in recent years by Federal Government policies and cutbacks, including the abolition of the Australian Preventive Health Agency, reducing spending on public health education campaigns, funding cuts for community organisations and programs undertaking preventive health activities and reduced policy emphasis on public health initiatives.

But both the Coalition and Labor have committed to trialling new models of chronic care in the primary health sector centred on general practice as the ‘home’ of health care and involving remuneration based not only on fee-for-service but also incorporating regular payments tied to the management of individual patients with complex and chronic illnesses.

But Public Health Association of Australia Chief Executive Officer Michael Moore said action was now needed.

“A lot of promises were made before the election to fight chronic disease,” Mr Moore said. “This research is the first of its kind, and should be taken as not only a warning, but as a call to action. What we need to see is action from the elected Government.”

Australia’s Health Tracker  can be viewed at: https://www.vu.edu.au/sites/default/files/AHPC/pdfs/australias-health-tr…

Adrian Rollins

[Seminar] Systemic amyloidosis

Tissue deposition of protein fibrils causes a group of rare diseases called systemic amyloidoses. This Seminar focuses on changes in their epidemiology, the current approach to diagnosis, and advances in treatment. Systemic light chain (AL) amyloidosis is the most common of these conditions, but wild-type transthyretin cardiac amyloidosis (ATTRwt) is increasingly being diagnosed. Typing of amyloid fibrils, a critical determinant of therapy, has improved with the wide availability of laser capture and mass spectrometry from fixed histological tissue sections.

Parents don’t know how much painkiller safe for kids

Many parents do not know safe doses of over-the-counter paracetamol products for their children, underlining concerns that large numbers of youngsters are being exposed to potential drug overdoses and other harmful outcomes.

University of Wollongong researchers have found that one in four parents do not know the recommended daily dose for paracetamol, and one in three are unaware that liver toxicity could result from an overdose of the painkiller.

Lead researcher Associate Professor Judy Mullan said the lack of knowledge among parents regarding the appropriate uses of paracetamol could leave children susceptible to potential adverse drug events.

NPS MedicineWise Medical Advisor Dr Andrew Boyden said that it is important, especially for parents, to understand that all medicines come with risks as well as benefits.

Related: Calls for paracetamol action

“Small mistakes can cause big problems in little bodies, so parents and carers need to know how to give medicines to children safely,” Dr Boyden said.

The study, involving 174 people, found that 26.4 per cent did not know the recommended maximum daily dose for children’s paracetamol, 37.4 per cent did not know that an overdose could cause liver toxicity, and 46 per cent were unsure how many days in a row the recommended dose could be given safely.

Participants in the study were mostly female (93 per cent), well educated (86 per cent), with a mean age of 36 years.

A/Professor Mullan said the findings showed that much more needed to be done to educate parents about the safe use of paracetamol in children.

“Some strategies to address knowledge gaps could include improving health professional/consumer communication, improving product packaging labelling, and improving media coverage about the potential adverse effects associated with incorrect dosage,” she suggested.

Related: Paracetamol overdose danger in obese children

Dr Boyden said that knowing how to accurately measure and administer medicines to children would help to avoid accidental overdosing or underdosing.

“Some ways to be medicinewise when children are involved include reading the medicine label and packaging, knowing the child’s weight, measuring liquid medicines accurately, keeping track of medicines given, and asking questions if you’re unsure about anything,” Dr Boyden said.

The paper was presented at the National Medicines Symposium. Read more at http://ro.uow.edu.au/smhpapers/3765/

Kirsty Waterford

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