Subscribe
×

Preference: Statistics, epidemiology and research design

1138

Hospitals get just $1 more

The Federal Government spent just an extra $1 for each man, woman and child in the country on hospital funding in 2013-14 as it screwed down hard on its health budget.

As the nation’s leaders meet for the last Council of Australian Governments meeting of the year, figures compiled by the Australian Institute of Health and Welfare show that Commonwealth funding for hospitals reached $892 per person in 2013-14, which was a $132 increase from a decade earlier but just $1 more than in 2012-13.

The miserly increase has contributed to a big shift in the burden of hospital funding from the Commonwealth to the other levels of government.

In the 10 years to 2013-14, spending by the states, territories and local governments on hospitals grew at virtually double the rate of the Federal Government.

Over that time, they expended an extra $10.3 billion on hospitals, after inflation – a 69 per cent increase.

During the same period, the Commonwealth’s contribution grew by just $5.7 billion – a 38 per cent increase.

The result provides a sobering backdrop to the tax reform debate.

Weak growth in GST revenues in recent years has intensified the strain of health spending on State and Territory budgets, driving calls by premiers and chief ministers for access to a more dynamic revenue base. One proposal has been to push the GST to 15 per cent and direct the funds to the Commonwealth. In return, the states and territories would get a share of income tax revenue.

But the Commonwealth flagged it is not interested in increasing the GST and is instead pressuring the states to change their own tax mix.

At the same the Federal Government has been paring back on hospital funding, it has been pulling back on its share of primary health spending, which dropped to 36.7 per cent in 2013-14 from 37.3 per cent the previous year.

Instead, it has picked up its spending on other health goods and services, particularly referred medical services, and to a lesser extent research and health administration.

In the 10 years to 2013-14, Commonwealth spending on these services jumped from $11.6 billion to $19.3 billion – including $12.2 billion on referred medical services alone.

Indicating the increasing importance of this type of spending, in 2003-04, it was 8.4 percentage points lower than Commonwealth spending on hospitals. Ten years later, it was just 2.3 percentage points lower.

The figures underline AMA concerns that the Commonwealth is dumping an increasing share of the health funding burden onto the states and territories, intensifying the strain on public hospitals, which have already reported a downturn in performance.

The Commonwealth’s backsliding on primary health funding also lends weight to fears that the reviews it has initiated into primary care, particularly the MBS Review, are being driven by a cost-cutting agenda.

Adrian Rollins

 

[Comment] China—a call for papers

In October, 2016, The Lancet will dedicate a weekly issue to health care and research in China—our seventh such themed issue since 2008. While we welcome submissions from China throughout the year and across all Lancet titles, the editors invite submissions of high quality research from China, or from research teams working on health in China, for this issue in particular. Submissions are welcome on all aspects of health science including, but not limited to: non-communicable disease control, health policies, and health-care reform in China.

[Comment] Tuberculosis—getting to zero

Reviewing research The Lancet has published on the global tuberculosis epidemic, one will be struck by how little the situation has changed over the years, and how the same calls to action get repeated from one year to the next. For decades, a piecemeal approach with a narrow treatment focus and a cost imperative has prevailed. The result? A global epidemic of disease. For more than a decade the global tuberculosis incidence rate has declined, but only slowly by about 1·65% annually.1,2 Meanwhile, the worst legacy of this disease has become multidrug resistance.

[Perspectives] We, the animals

In 1981, a group of 17 macaques known as the Silver Spring Monkeys became the most famous research animals in the USA when Alex Pacheco, an undercover college student and animal rights activist, infiltrated the laboratory of psychologist Edward Taub to expose the experiments that took place inside. In his research on neuroplasticity, Taub severed the afferent ganglia to certain limbs while immobilising the limbs that were neurologically intact in an attempt to train the macaques to use the appendages that lacked neural feedback.

[Perspectives] Evan Wood—bringing change to addiction medicine

Evan Wood had not thought much about a career in medicine having studied geography, but an assignment to chart the diffusion of HIV around Vancouver, Canada, got him hooked on clinical epidemiology. Today Wood is Professor of Medicine at the University of British Columbia and a leader of addiction medicine at St Paul’s Hospital and the local health authority in Vancouver, where he works to improve systems of care for patients with addictions. As Wood points out, “Addiction science has gotten so far ahead of what the health system actually delivers in terms of care.

FBT cap: we are not entertained

Patients could face a blow-out in waiting times for elective surgery if the Federal Government pushes ahead with controversial plans to cap tax concessions on entertainment benefits for hospital employees, the AMA has warned.

The nation’s peak medical group had told Treasury its proposal to impose a $5000 cap on salary sacrificed meal and entertainment expenses that are eligible for fringe benefit tax exemptions would harm the ability of public hospitals and other not-for-profit health groups to attract and retain skilled medical staff, undermining the services they are able to provide.

In its May Budget, the Federal Government claimed the tax concession – currently worth around $17,000 a year – was being exploited and abused, and estimated its crackdown on the perk would raise $295 million over four years.

But AMA Vice President Dr Stephen Parnis said the Government had not provided any substantive evidence to back its claim FBT concessions were being used unfairly, and urged it to proceed with great caution in making any changes.

“The AMA is deeply concerned that the reforms canvassed in the exposure draft could significantly affect the ability of institutions, including public hospitals, to recruit and retain staff,” Dr Parnis said, warning this could cause treatment waiting times to blow out.

“If the current supply of medical specialists decreases, we believe it is reasonable to predict a lengthening of waiting lists for elective surgery and outpatient clinics.”

Public hospitals and not-for-profits have relied on the FBT concession to help them compete with the private sector for the services of doctors and other health workers.

Dr Parnis said that many practitioners chose to forego higher wages on offer in the private sector to work in public hospitals because of the chance to practice advanced acute care, undertake research and provide teaching and training.

But he said they still deserved to be fairly remunerated for their skills and experience, and the FBT tax concession helped to make the salaries hospitals could offer competitive.

The AMA has warned that putting a cap on the concession would have a number of serious unintended consequences for the health care system, particularly the supply of medical specialists.

In the short-term, any drift of medical specialists away from the public system will likely cause waiting lists for surgery to blow out.

In the longer term, because the health system relies on senior and experienced hospital medical staff to help train the next generation of practitioners, Dr Parnis said the loss of even some of these workers to the private sector because of reduced tax breaks would undermine teaching capacity.

He said this was particularly worrying because it was coming at a time when the pressure on hospital teaching capacity had never been greater as a result of rapid growth in the number of medical graduates.

Several organisations have written to Treasury urging that the $5000 cap on entertainment expenses that are eligible for FBT exemptions be raised.

St John’s Ambulance said it relied on the FBT exemption to help attract and retain skilled staff, and suggest the cap be increased to $20,000, while the Fred Hollows Foundation recommended it be set at $30,000.

The Salvation Army, meanwhile, warned a $5000 cap would hit the salaries of half its staff.

The Tax Institute recommended the bcap be set at $15,000.

The tax change is due to come into effect from 1 April 2016.

Adrian Rollins

 

New treatment to overcome peanut allergies in children

By Jane Trembath, Southern Health News / 4th of November, 2015

This story was first published by The Lead, South Australia.

A new study is successfully helping children to overcome peanut allergies by exposing them to peanuts and desensitising them to their allergy.

For the past four years, paediatric allergist Dr Billy Tao has been developing a novel two-step desensitisation process at Flinders Medical Centre (FMC) in South Australia.

The first step involves boiling peanuts for an extended length of time to make them less allergenic.

The boiled peanuts are given to patients to partially desensitise them, and then once the patient shows no signs of allergic reaction, roasted peanuts are given to the children to increase their tolerance in the second step of the process.

Dr Tao said the low-cost and effective two-step process resulted in less adverse events than previously used single-step desensitisation methods – also known as oral immunotherapy.

“With traditional methods, a lot of people ingesting increasing amounts of roasted peanut flour or similar products start to react – so much so that many have to drop out and can’t finish the treatment,” Dr Tao said.

The FMC trial is carried out over a year or longer and includes patients aged between 10 and 15 years.

Of the 14 participants, 10 have already completed the first step and are now eating varying amounts of roasted peanuts, while four continue to eat boiled peanuts and are progressing well.

“One patient who had to be administered three adrenaline injections after consuming peanuts is now eating several roasted peanuts every day without problems,” Dr Tao said.

Studies show the number of children living with peanut allergy appears to have tripled between 1997 and 2008, and as many as one in every 200 children will have severe allergy to nuts.

Allergy symptoms can vary from very mild (including tingling mouth, puffy lips and welts around the mouth) to moderate symptoms (facial swelling, body rash, runny nose and red eyes, abdominal pains and vomiting); while severe reactions include trouble breathing, looking pale and unwell, and anaphylaxis.  Very occasionally death may result from a most severe reaction. 

Dr Tao’s idea for hypo-allergenic (less allergenic) nuts to be consumed first was based on an observation by German researcher Professor Kirsten Beyer, who in 2001 noted that peanut allergies were less prevalent in China than the western world because the Chinese ate boiled peanuts rather than peanut butter or roasted peanuts. She found that boiling peanuts for 20 minutes made them less allergenic than roasted peanuts.

Dr Tao said that a partnership with Dr Tim Chataway, Head of the Flinders Proteomics Facility, and Professor Kevin Forsyth from the FMC Paediatrics Department, proved that peanuts boiled for at least two hours were less allergenic and the pair designed a study using this immunotherapy approach.

Dr Tao hopes his research could one day be carried out in a doctor’s clinic and then at home and avoid the need for hospital-based treatment.

However he strongly warned people against ‘do-it-yourself’ desensitisation at home and stressed that patients should be seen by an allergist and individual care plans developed.

Among those who have already undergone Dr Tao’s new desensitisation method is 16-year-old Shehan Nanayakkara, who was diagnosed with a severe peanut allergy at the age of three.

“We first realised Shehan had an allergy when friends gave him a peanut butter sandwich and he had to be rushed to hospital…there have been many accidents since then,” father Asanka said.

“During one round of allergy testing he ended up in the Intensive Care Unit – that time I thought I’d lost him.

“I approached Dr Tao to help and at first Shehan ate boiled peanuts, working his way up to consuming 13 a day, and now he eats five normal roasted peanuts daily, mixed in with his meals.

“It’s been a big relief because children and teenagers don’t care too much about what they eat and just eat whatever, and there has always been that worry that something might happen – now we can relax a bit because Shehan has some tolerance.”

 

Atlas charts course to improved care

The first detailed national appraisal of variations in health practice has found that Australians are among the world’s heaviest users of antibiotics and antidepressants, and within the country there are major differences in the use of common drugs and treatments for everything from colonoscopies and cataract surgery to antipsychotic medicines for the elderly and hyperactivity drugs for the young.

In what is seen as the first step toward addressing unwarranted variations in the care patients receive, the Australian Commission on Safety and Quality in Healthcare has released a report identifying wide discrepancies in the use of everyday medicines and procedures.

Among its findings, the Australian Atlas of Healthcare Variation has revealed that children in some parts of the country, particularly in NSW, are seven times more likely to be prescribed drugs for ADHD than those in other areas, while cataract surgery, hysterectomies, tonsillectomies were three times more common in some areas than others, and patients in some parts were 30 times more likely to undergo a colonoscopy.

AMA President Professor Brian Owler said that, by reflecting how the delivery of health care was organised, the Atlas provided a useful illustration of differences in access to care.

But he highlighted the fact that the Commission itself made no claim about the degree to which differences in care was unwarranted.

“The Atlas is a welcome starting point for further research and examination of health service distribution,” Professor Owler said. “It is not proof that unnecessary or wasteful care is being provided to Australians, and should not be interpreted that way.”

The Commission said that some variation was “desirable and warranted” to the extent that it reflected differences in preferences and the need for care.

It added that “it is not possible at this time to conclude what proportion of this variation is unwarranted, or to comment on the relative performance of health services and clinicians in one area compared with another”.

Senior clinical adviser to the Commission, Professor Anne Duggan, said the average frequency of various services and procedures provided in the Atlas were not necessarily the ideal, and observed that “high or low rates are not necessarily good or bad”.

Nonetheless, she said the weight of local and international evidence suggested much of the differences observed was likely to be unwarranted.

“It may reflect differences in clinicians’ practices, in the organisation of health care, and in people’s access to services,” Professor Duggan said. “It may also reflect poor-quality care that is not in accordance with evidence-based practice.”

Many of the variations identified in the Atlas have been linked to wealth and reduced access to health care in disadvantaged areas.

Professor Duggan said the less well-off tended to have poorer health and so a greater need for care, while some procedures are used more often in wealthier areas.

She said the Atlas showed that rates of cataract surgery were lowest in areas of disadvantage, and increased in better-off locales.

But Professor Owler said the example showed the need to be very careful in drawing conclusions about the reasons for variation.

He said the Atlas showed that the incidence of cataract surgery was highest in the remotest parts of far north Queensland.

“This is because there are no public services available, with private ophthalmologists delivering eye care to Indigenous communities, which is covered by Medicare,” the AMA President said.

He said identifying variation in health care was essential, but this was the first step before determining the causes of variation.

“The Atlas doesn’t tell us what should be the best rates for different interventions and treatments.”

In addition to identifying variations in health care within the country, the Atlas also explored how the care provided in Australia compared internationally.

While acknowledging that differences in the type and quality of data made it difficult to draw direct comparisons, the Atlas nonetheless reported that Australia has “very high” rates of antibiotic use compared with some countries, and Professor Duggan said that, among rich countries, Australia was second only to Iceland in the extant of use of antidepressants.

Professor Owler said that, with the publication of the Atlas, the challenge now was to develop a process to identify variations in practice that were “actually unwarranted, not just assumed to be” and to develop and fund strategies to reduce them by supporting clinically appropriate care, such as by providing clinical services where they are needed.

To view the Atlas, visit: http://www.safetyandquality.gov.au/atlas/

Adrian Rollins

[Perspectives] Suzanne Petroni: pushing equity for girls and young women

Next year, the International Center for Research on Women (ICRW), based in Washington, DC, USA, will celebrate its 40th birthday, and singing loudly will be its Senior Director for Gender Population Development, Suzanne Petroni. “Our main focus is on promoting gender equality and empowering women and girls, particularly in low-income and middle-income countries”, she says. “Our work goes deep into the causes and contexts of gender inequity, as we seek to better understand, for example, how to end the harmful practice of child marriage, how to increase access to sexual and reproductive health and rights, and why it is that suicide has overtaken maternal mortality as the leading cause of death among adolescent girls globally.”