more_vertAlmost 30 years before the 2011 landmark report of the US Institute of Medicine (IOM) on health disparities among lesbian, gay, bisexual, and transgender (LGBT) people, Judith Bradford did one of the first community research investigations of HIV/AIDS in gay men. At that time, Bradford says, this “hidden population” was not eager to answer questions about their personal lives for the survey she was doing for Virginia state Department of Health. The survey was a challenge she now describes as “an opportunity” that would become her PhD dissertation at the Virginia Commonwealth University (VCU) and set her on a course that determined her life’s work as a population scientist.
Preference: Statistics, epidemiology and research design
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When not doing something may be the best choice
X-rays for sprained ankles, antibiotics for ear infections and colds and colonoscopies to screen for bowel cancer are among more than 60 tests, treatments and procedures medical experts say should be avoided because they are wasteful and unnecessarily risky.
Fourteen specialist colleges, societies and associations have taken the lead in identifying 61 tests and procedures that should no longer be used because they expose patients to harm, undermine the effectiveness of lifesaving antibiotics and are a poor use of scarce health dollars.
The list, compiled under the Choosing Wisely initiative of NPS Medicinewise, includes many practices and treatments often considered routine and uncontroversial, but which evidence shows achieve little and are potentially harmful.
An area of particular focus is the use of antibiotics, amid fears that they are being overused, fostering bacterial resistance and the rise of superbugs impervious to known medicines.
In changes that could improve patient outcomes and potentially save millions of dollars, doctors and parents are being urged to make much more careful use of antibiotics, including in the treatment of middle ear infections in children, and in the treatment of colds and other upper respiratory tract infections.
The Royal Australian College of General Practitioners (RACGP) has recommended against the initial use of antibiotics for children aged between two and 12 years with a middle ear infection, where a review is possible in the following 24 to 48 hours.
AMA President Professor Brian Owler said it was important advice that would avert unnecessary treatment while helping to preserve the effectiveness of antibiotics.
“In the case of an ear infection, if there is a chance of review in 24 to 48 hours and the ear looks red, just come back and have a review rather than going straight to antibiotics, so that we try and reduce this over-prescribing of antibiotics,” Professor Owler told Channel Nine’s Today show.
The AMA President said it was advice aimed not only at doctors, but also parents and patients.
“Part of the problem here is not just to educate doctors in terms of when antibiotic prescribing is or isn’t called for, it is also to educate parents and patients themselves so that we don’t prescribe too many antibiotics, because we know if we do that we are likely to see more resistant infections. That’s going to mean that people’s infections are going to be much harder to treat in the future,” he said.
Two Bond University academics, Professor of Clinical Epidemiology Tammy Hoffmann and Professor of Public Health Chris Del Mar said the Choosing Wisely initiative was important not because of the money that could be saved, but because of a change in a approach that it represented.
They wrote in The Conversation that clinicians were guilty of doing too much rather than too little, and Choosing Wisely helped to signal “a very important departure from normal business for clinicians – thinking about not doing things”.
“The premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients,” they wrote.
Other therapies that have come under question include chest x-rays, one of the test most commonly ordered by GPs.
The RACGP has advised that GPs should no longer, as a matter of routine, order chest x-rays for patients with acute uncomplicated bronchitis.
The Royal Australasian College of Surgeons, meanwhile, has recommended against CT scans for suspected appendicitis without first considering an ultrasound, the Australian Physiotherapy Association has advised that there is “no advantage from routine imaging of non-specific low back pain”, and the Australian and New Zealand Society of Palliative Medicine has advised against the use of stomach feed tubes for patients with advanced dementia.
Professor Owler said the initiative demonstrated that doctors were keen to get rid of wasteful and potentially harmful practices, and supported efforts to improve the effectiveness of health spending.
He said doctors took seriously their responsibility as stewards of the health care system, and were constantly reviewing their practices and the evidence to ensure patients received the best possible care.
His comments were echoed by Australasian College of Dermatologists President Associate Professor Chris Baker, who said that one of the challenges of modern medicine was to determine which of the multiplicity of tests and treatments available were of benefit to patients.
A/Professor Baker said his College had identified several instances where the use of antibiotics was unnecessary and could help undermine their effectiveness, including in the treatment of acne vulgaris, epidermal cysts and redness and swelling of both lower legs.
The Choosing Wisely campaign is running in parallel with, but is unrelated to, a Federal Government taskforce review of the Medicare Benefits Schedule, which was set up last year and is not expected to complete its work until 2017.
The goal of updating the MBS to reflect modern clinical practice has been backed by the AMA, but there are concerns that the Government wants to use it primarily as a cost-cutting exercise that will be quick to de-list old treatments but slow to add new ones.
Adrian Rollins
Postcode perils
Is your neighbourhood making you fat? That is the question a group of Europe-based researchers set out to answer in a unique study aimed at finding out what it is about where people live that has an impact on their diet and exercise habits.
Analysing data from more than 6000 people living in Paris, London, Ghent, Rotterdam, Amsterdam and Budapest, they found that levels of physical activity, self-rated health and happiness were associated with how people perceived and used their neighbourhood.
In a result that has big implications for urban planning and design, the study found that residents of lower socio-economic areas perceived their environment as less conducive to healthy behaviour than those in more affluent areas. Surveys found that neighbourhood perception was not only associated with objective features such as traffic safety and aesthetics, but also with social cohesion.
Higher levels of social networking and cohesion were associated with better self-rated health, lower odds of obesity and higher fruit consumption.
The four-year SPOTLIGHT study was supported by Google Street View, which assisted in measuring factors such as green spaces, street layout and food outlets in different areas. Features such as the presence of food outlets, outdoor recreation facilities, and green spaces varied significantly between the cities included in the study.
Lead researcher Jeroen Lakerveld from the VU University Medical Centre in Amsterdam said in future, neighbourhoods should be designed on the basis of how their structures will affect the physical health of inhabitants.
“Urban planners and policy makers have a responsibility to ensure the neighbourhoods they design, and the facilities and businesses that the neighbourhoods contain, will promote health behaviour, and is protective against unhealthy behaviours,” Dr Lakerveld said.
“It could save millions in health care costs if health promotion focuses on upstream determinants of healthy behaviours, including healthy food purchases and greater physical activity.
“The best neighbourhoods are those which facilities to support good health and also encourage social networking and community support.”
Co-editor Dr Harry Rutter, from the London School of Hygiene and Tropical Medicine, said the collection of papers provides a robust evidence based for policy makers.
“We have known for some years that where a person lives will affect their health, and now we can see more clearly exactly how that happens and, in practice, what we need to do about it,” Dr Rutter said.
The SPOTLIGHT project is funded by the European Commission, and the study was published in Obesity Reviews.
Kirsty Waterford
[Comment] Pharmacogenetics of lithium response: close to clinical practice?
The beliefs that genes are the root of diseases and that genomics has the potential to help us screen, diagnose, predict, and treat disease are particularly compelling in cancer research.1,2 However, human genomic research focusing on mental disorders and other complex illnesses is at a fairly early stage, with no best approach yet identified to study complex diseases such as bipolar disorder. Genes associated with risk for bipolar disorder have been searched with candidate gene and genome-wide association approaches.
A nation in pain
Australians are world champion pill poppers, quadrupling their use of common opioid-based painkillers such as codeine, morphine, and oxycodone in the last decade, an international study has found.
Researchers from the independent body responsible for implementing the United Nations international drug control conventions, the International Narcotics Control Board, found that the use of opioid painkillers in Australia rose from 22 million doses annually in 2001 to 106 million doses annually in 2013.
Though there has been a worldwide trend toward greater reliance on painkillers, Australia is one of a handful of regions that accounted for the vast bulk of increase in their use.
The INCB study, which examined the consumption of the painkillers, and the prevalence of disorders that needed them, in 214 countries, found that overall opioid painkiller use had doubled since 2001. But Australia, North America, Western and Central Europe and New Zealand accounting for more than 95 per cent of global opioid use.
While researchers speculated the higher usage in developed countries could be due to increased pain management for cancer in aging populations and other chronic illnesses, low-income and developing countries, which have higher rates of the diseases for which opioid medications are needed, had little access to the drugs, and there was no significant increase in their use.
Co-author of the study, Professor Richard Mattick, from the University of New South Wales’ National Drug and Alcohol Research Centre, said that there were a number of factors that made it difficult for patients in in developing countries to get painkillers, particularly cost, but also including a lack of training among medical professionals and fear of dependence.
Professor Mattick told The Guardian that because there was no recognised level of appropriate prescribing and dosage for opioids, it was hard to tell if their use in Australia was excessive or inappropriate.
“You can’t have benefits without some harms; it’s just nonsense to think otherwise,” Professor Mattick said.
“So, while it’s correct to bring attention to harms, I think we have some work to do to understand this situation accurately, and to get a comprehensive national picture of what is driving this use.”
The study was published in the Lancet.
Kirsty Waterford
Health on the Hill – briefs
Dying with dignity
Laws legalising euthanasia in the ACT and the Northern Territory would be reinstated under a Bill introduced to the Senate with the support of a group of MPs drawn from across the major parties.
In a rare display of cross-party action, Labor MPs including Alannah Mactiernan, Katy Gallagher and Nova Peris have joined with Liberal MP Sharman Stone and Australian Greens leader Richard Di Natale in backing legislation which would restore to the ACT and the NT the right to legislate around euthanasia.
The new laws would roll back a Private Member’s Bill, introduced by Liberal MP Kevin Andrews in 1996, that nullified NT euthanasia legislation and stripped the ACT of the power to legislate for euthanasia.
The issue is politically divisive, and the Labor caucus last month decided to allow ALP MPs a conscience vote on the matter.
The push to allow for euthanasia has gathered momentum in recent months and has the backing of several high-profile advocates including broadcaster Andrew Denton.
But even if the legislation is passed by the Senate, there are doubts it will attract sufficient support in the Lower House to become law.
Indecent disclosure
Health care providers are set to come under scrutiny over the adequacy of their information disclosure as the consumer watchdog vows to crack down on confusing and misleading conduct.
Australian Competition and Consumer Commission Chair Rod Sims said the agency had “important investigations underway” into the disclosure practices of health care providers amid concerns some were in breach of Australian Consumer Law.
Flushed with success after forcing Canberra’s Calvary Private Hospital to provide patients with more information about potential out-of-pocket costs, Mr Sims said the ACCC would focus on shortcomings in disclosure to consumers.
He said the Commission’s scathing report on the behaviour of the private health insurance industry, released last year, would provide a springboard for greater scrutiny regarding the provision of incomplete information that was not only confusing but potentially misleading.
Research boost
Research to develop an AIDS vaccine and reduce the incidence of over-diagnosis are among 96 projects sharing $130 million of funding in the latest round of grants from the nation’s peak medical research organisation.
Health Minister Sussan Ley said the money was part of $850 million that will be disbursed by the National Health and Medical Research Council to fund a wide range of projects.
There has been criticism that scientists starting their research career have often been unfairly overlooked in the race for funding, but NHMRC Chief Executive Officer Professor Anne Kelso said grants were awarded to a mix of both “outstanding new talent and experienced and internationally recognised researchers”.
TPP
Drug companies may effectively hold at least an eight-year monopoly on the supply of expensive biologic medicines under the terms of the controversial Trans Pacific Partnership trade deal, activists have warned.
Trade watchers have seized on remarks made by Australia’s Special Trade Envoy, Andrew Robb, during a visit to Washington DC late last month to claim the Government was looking at using administrative delays and other bureaucratic processes to effectively extend monopoly protection for biologic medicine manufacturers to eight years – three years longer than stipulated under the treaty.
The Washing-based Politico news service reported assurances from Mr Robb, who was visiting the US capital to help rally US Congress support for the TPP, that the trade agreement would effectively provide at least eight years market protection for biologic makers, as possibly as long as 17 years.
During negotiations for the TPP, Australia and other countries resisted US demands for at least 12 years of data protection for biologic manufacturers, and there was eventual agreement on a “five-plus” approach guaranteeing makers a minimum of five years’ monopoly on supply.
Though Mr Robb told Politico Australia would not be “a party to anything that would imply that we’ve changed our position”, he emphasised the importance of providing drug companies similar protection to that they received in the US: “We’ve got a very burgeoning biologics sector in Australia, [and] if they weren’t getting the protection that they could get in the United States, they wouldn’t be setting up in Australia”.
Health advocates warn this would effectively mean at least eight years before cheaper generic versions of expensive biologic medicines – gene and cellular-based therapies that are being developed to treat diseases long-considered intractable, such as cancer, HIV/AIDS, rheumatoid arthritis, diabetes, hepatitis B and multiple sclerosis – would become available.
Get moving
Teenage girls are being urged to ‘make your move’ following findings that they are, on average, only half as physically active as their male counterparts.
Health Minister Sussan Ley has launched the #girlsmakeyourmove campaign to encourage young women to play sport and engage in other activities amid concerns many are heading for a life of poor health.
Ms Ley said research showed almost 60 per cent of girls aged between 15 and 17 years undertook little or no exercise, compared with a third of boys in the same age group.
The Minister said such sedentary habits, particularly during the formative teenage years, could lead to a lifetime of chronic disease.
“[This campaign] aims to tackle this sliding door moment in a young woman’s life when they actually are laying down the foundation for the rest of their lives,” Ms Ley said. “Physical activity in the teenage years lays down the muscle and bone you need for the rest of your life.”
Many girls get put off playing sport or engaging in physical activity because of a lack of confidence, fear of being judged or a bad experience, and the campaign uses television ads and social media to feature girls enjoying playing sport and being active.
Rural practice the prize for Australian Medicine reader survey winner
Caption: Australian Medicine reader survey winner Jezreel Blanco receives her Apple iPad Pro from AMA President Professor Brian Owler
As she prepares to embark on a career as a rural GP, Australian Medicine reader survey winner Jezreel Blanco’s one concern about winning the latest generation Apple iPad Pro is that it will out-match the speed of bush internet connections.
Adelaide-based Jezreel won the iPad after her name was randomly selected from more than 1500 readers who took part in the Australian Medicine survey, and was excited to receive the prize from AMA President Professor Brian Owler earlier this week.
The GP trainee is currently a resident at Flinders Medical Centre and is busily accruing the skills and experience she thinks will be vital to working as a general practitioner in a rural practice. She has already spent some time in obstetrics and paediatrics, and is currently working in an emergency department, where she hopes to gain experience in trauma care.
It is quite a shift in focus from Jezreel’s initial career as a medical scientist. Following a four-year degree at Sydney University, she worked in a coordinating centre for neonatal research, which she found to be too removed from the frontline of care for her liking.
“We were doing research on neonatal illnesses, but I never got to meet the families who were effected,” Jezreel said. “I was very interested in meeting with them and working them.”
It was this realisation that spurred her to undertake a medical degree, and to soon become a rural GP – even if the internet access isn’t great.
Adrian Rollins
[Correspondence] Utilising additional sources of information on microcephaly
When the Zika virus outbreak was declared a Public Health Emergency of International Concern on Feb 1, 2016, the WHO International Health Regulations Emergency Committee made several recommendations. One of them was for increased research into the aetiology of clusters of microcephaly and its link to Zika virus.1 Quantification of microcephaly incidence is now a pressing requirement to estimate the proportion of cases that might be attributable to Zika virus infection. However, most countries that are at risk of Zika virus transmission because of the presence of Aedes mosquitoes have weak health-care systems and even weaker surveillance systems.
[Correspondence] Biomedical research in Latin America: we can do more
On Nov 12, 2015, hundreds of researchers took to the streets of several cities in Chile to protest against the scarce research funding, which was only up to 0·39% of the country’s gross domestic product (GDP) in 2013.1 The low investment in research worries many scientists, especially biomedical researchers in Latin America.
[Perspectives] Kathy Niakan: at the forefront of gene editing in embryos
Kathy Niakan is keen from the outset to keep our conversation about science. Since she was granted a licence this February by the UK Human Fertilisation and Embryology Authority (HFEA) to edit the genes of human embryos for research purposes, her group at the Francis Crick Institute’s Mill Hill Laboratory in London has been under intense media scrutiny. The HFEA’s decision is the first time a regulatory body has given permission for such work, and it has led to claims that this is a first step towards gene-edited “designer babies”.