more_vert“Why are you helping me?” he asked. “I’m a doctor”, I replied. I wasn’t, technically. I was a medical student, and although I’d finished clinical rotations and matched into surgery, I was not a doctor quite yet. But blood was pouring from the man’s face and we were nowhere near a medical facility, so I spoke with the unfounded bravado of a young doctor-to-be.
Preference: Surgery
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Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study [Research]
BACKGROUND:
Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs.
METHODS:
We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk.
RESULTS:
Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30–1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18–2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01–1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01–1.11).
INTERPRETATION:
Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.
[Comment] Health in focus: 2017 Highlights photography competition is open for submissions
Photographs are an immediate and compelling way to communicate—they can entertain, educate, inspire, outrage, or move us. They can be a powerful way to focus on important health stories and capture and make permanent those fleeting moments that matter in medicine. The Lancet’s annual photography competition, Highlights, is now open for entries. We are looking for striking, original pictures on any health topic, from clinical medicine to global health, from the individual person to populations. Some of the winning photographs in last year’s competition highlighted the need for clean water and surgery in Africa and the plight of refugees with mental disorders.
[Comment] Bioprosthetic surgical and transcatheter heart valve thrombosis
Excellent outcomes of transcatheter aortic valve replacement (TAVR) have been experienced by patients with aortic stenosis at high and intermediate risk of surgery.1 Findings from large randomised trials1,2 have shown survival with TAVR that is similar to or improved compared with bioprosthetic surgical aortic valve replacement (SAVR), and very low stroke rates have been observed with new-generation devices. Investigators of echocardiographic follow-up studies3 have consistently reported low transvalvular gradients up to 5 years after TAVR and SAVR, with slightly greater aortic valve areas after TAVR than after SAVR.
AMA Gold Medal presented for exceptional service to a ‘one of a kind’
Dr William Glasson AO, the AMA President who steered a course through the medical indemnity crisis in the early 2000s, has been recognised with the highest honour the peak medical body can bestow – the AMA Gold Medal.
Dr Glasson, universally known as Bill, received the Medal in recognition of his exceptional service to the AMA over many years, and his long-term and ongoing commitment to the eye health of Indigenous people.
AMA President, Dr Michael Gannon, who nominated Dr Glasson for the Medal, said that the distinguished ophthalmologist is one of a kind – a truly deserving recipient of the AMA Gold Medal.
Dr Gannon said: “Bill’s generosity and altruism know no bounds. His work extends to outback Queensland, Indigenous communities, and East Timor.
“Bill was always a strong and passionate advocate for the AMA, the medical profession, the health system, and patients throughout his time as President, at both State and national level.”
Dr Gannon acknowledged when presenting the award that Dr Glasson’s leadership produced a very positive outcome for the profession and the Australian people, following many years of hard work by his predecessors, the AMA Federal Council, and the State and Territory AMAs.
“His hours, days, and weeks of tense negotiations with the then Health Minister Tony Abbott paid off. Bill and Tony survived those tough days, and remain close friends to this day,” Dr Gannon said.
“Bill always wears his heart on his sleeve. His style of advocacy is direct and to the point, tinged with a typical Queensland bush sense of humour, which reflects his origins in outback Winton, and characterised by his expert use of the Australian vernacular.”
Dr Glasson has been President of the Royal Australian and New Zealand College of Ophthalmologists.
He is a member of professional organisations such as the Royal Australasian College of Surgeons, the American Academy of Ophthalmology, the Australian Society of Cataract and Refractive Surgery, the American Society of Cataract and Refractive Surgery, and the Australian Optometry Association.
Dr Glasson is an Adjunct Associate Professor with the University of Queensland School of Medicine.
Meredith Horne
AMA lends support to build the Indigenous health workforce
As a 13-year-old, James Chapman watched his father, a proud Indigenous man from Yuwlaaraay country, die after a short, seven-week battle with acute myeloid leukaemia. As a school leaver, he became his mother’s carer for 12 months as she recovered from brain surgery.
Today, the 25-year-old, second-year medical student has won the 2017 AMA Indigenous Medical Scholarship – $10,000 a year for each year of study – to help him pursue his dream of becoming a medical professional.
AMA President Dr Michael Gannon, who presented the Scholarship at the AMA National Conference in Melbourne said that Mr Chapman’s story was inspiring.
Dr Gannon believes the award is important because Indigenous people have improved health outcomes when they are treated by Indigenous doctors and health professionals. This is highlighted by the need to build the building the Indigenous health workforce where in 2017, there are just 281 medical practitioners employed in Australia as Aboriginal or Torres Strait Islander – representing 0.3 per cent of the workforce.
Mr Chapman said that while he did not realise it at the time, his father was a victim of the gap that exists between Indigenous and non-Indigenous Australians when he saw firsthand communities with access only to a visiting doctor and nurse.
He dreamed of one day becoming a doctor, but was discouraged by his teachers. As a young student at the University of Wollongong his study was derailed when his mother was diagnosed with a brain tumour, and he became her carer for a year while she recovered.
“Constantly in clinical environments, my dream of becoming a medical professional became more intense, and after my mother recovered, I began a Science degree with the intention of completing post graduate medicine,” Mr Chapman said.
Now in his second year, Mr Chapman intends to study from Wagga Wagga from his third year onwards to experience rural health, and rural and remote Indigenous health care. He hopes to become a GP, working with Indigenous women and children in rural and remote Australia.
Dr Gannon said that, in 2017, a total of 286 Aboriginal and Torres Strait Islander medical students are enrolled across all year levels across Australia. However, four of the 15 colleges are yet to have an Indigenous trainee.
“The AMA Scholarship has assisted many Indigenous men and women, who may not have otherwise had the financial resources to study medicine, to graduate to work in Indigenous and mainstream health services,” Dr Gannon said.
The AMA Indigenous Medical Scholarship was established in 1994 with a contribution from the Commonwealth Government. The AMA is looking for further sponsorships to continue this important contribution to Indigenous health.
Donations are tax-deductible. For more information, go to advocacy/indigenous-peoples-medical-scholarship
Meredith Horne
Obesity Epidemic: Time for a rethink. Time for action. Time for leadership.
BY AMA VICE PRESIDENT DR TONY BARTONE
There is no shortage of axioms we associate with this topic. “Obesity is a life style disease.” “It is a matter of choice.” “It’s a disease of modern society.” “It’s a matter of too much in and not enough out.” Right? If only it was that simple. The only thing we can hand-on-heart truly say is that it is a multifactorial problem that requires a multi-pronged approach.
Recently at the AMA National Conference in Melbourne, I had the pleasure of being part of a panel (https://natcon.ama.com.au/session/tackling-obesity) discussing the multiple facets of what is the obesity epidemic and what needs to happen if we are to curb this rapidly progressing threat to our lifestyle and our health outcomes.
The panel facilitated by Professor Brad Frankum included Professor Stephen Duckett, Professor Steve Allender, Jane Fleming OAM; Mr Ahmad Aly, Dr Geoffrey Annison.
What was clear from the discussion was that the problem is immense. With two-thirds of Australians either overweight and or obese we are under no illusion. Recent Australian Institute of Health and Welfare data shows that it is even greater among men where there appears to be a social acceptance around their significant excess weight.
However, what is clear from the discussion is that we need to start looking at obesity as more than just an individual condition. We need to look at it at various levels, with many different strategic approaches focusing at individual, community and public health levels, as well as at government and regulatory perspectives, if we are going to achieve changes.
We need to seriously consider the evidence emerging that it is a biological disease; one that has its underlying components in genetic predisposition and one that has its expression in an obesogenic environment that is modern society.
Furthermore, this emerging body of opinion makes the point of the existence of a primitive response mechanism of our bodies to maintain and resist attempts at dieting, defending our weight through a raft of physiological and hormonal changes in response to the weight loss and defending the set predetermined weight. Hence, we can understand the resultant yo-yo weight loss/gain our patients report in response to many attempts at losing weight.
Clearly, prevention is extremely crucial but is not the sole solution. However its role cannot be diminished. It is cheaper to prevent a problem than to solve it. Being a GP, this is firmly underpinning all our efforts in lifestyle advice and behaviour modification that we discuss with our patients. GPs are ideally positioned to initiate the conversation with our patients and assists our patients with their journey in dealing with their situation. Furthermore, GPs, I believe, have a unique place in the communities they are part of and need to lead and be a part of the community solution.
The issue of a sugar tax came under the spotlight. Even though evidence was presented by Professors Allender and Duckett that a sugar tax cut directly led to modifying or a change in consumption behaviour and to a lesser extent to a reduction in weight (particularly in the Mexico example), such evidence was ignored by Dr Annison of the Food & Grocery Council who still, along with others, believes that moderation of intake and appropriate lifestyle choice is the sole solution to the problem.
Prof Duckett beautifully made the point that he felt a sugar tax was inevitable. Political overtones from the sugar production electorates would be a significant obstacle in the short term. He did make the point that if the politicians representing these electorates, which also have some of the highest levels of obesity, did not recognise the impacts on the health of their constituents, and did not make the hard decisions, why on earth are we paying them. The importance of top-line government/ industry measures was further emphasised, as was more robust food labelling requirements.
Effort in this space must be proportional to the size of the problem. Prof Allender illustrated the comparison with a viral global epidemic led to two-thirds infection rate with a resulting 20year life expectancy outcome. The border response at our airports in the face of a possible virus would be absolutely enormous and immediate.
Communities need to be empowered to develop solutions to lead the change. Studies are showing that a local community level reduction of 5 per cent in obesity in children, over a two-year timeframe, can lead to immediate health improvements and a reduction in the burden of mental health issues.
The appropriateness of bariatric surgery as an intervention in obesity needs to be well understood and supported by public health and government interventions, especially when it comes to public hospital funding. It is clear that bariatric surgery is not an isolated intervention but part of a suite a measures that is a lifelong contract by the patient.
Physical activity is equally important but the role of gyms as being the sole solution is being beautifully challenged by the work of people like Jane Fleming. Participants aged between 18 and 87 frequenting her community-led physical activity programs, reveal the success of a program deserving closer attention and more support.
Fearless, strong leadership from the very top is required in this space. National governments and authorities can provide the coordination. But there needs to be leadership to facilitate a multi-pronged suite of policy and other interventions focusing at every level in the discussion – from Government right down to the individual choices and response. Our position statement outlines a suite of measures and initiatives at every level and no one, single measure is more important or acceptable in isolation. It does provide a pathway or a roadmap to guide advocacy and the basis for further engagement. Ultimately, every part of the medical profession has a role to play in leading their community and their profession in the future solution to this epidemic of the 21st century.
[Series] Strategies for long-term preservation of kidney graft function
Kidney transplantation has become a routine procedure in the treatment of patients with kidney failure, and requires collaboration of experts from different disciplines, such as nephrology, surgery, immunology, pathology, infectious disease medicine, cardiology, and oncology. Grafts can be obtained from deceased or living donors, with different logistical requirements and implications for long-term graft patency. 1-year graft survival rates are greater than 95% in many centres but improvement of long-term function remains a challenge.
Weight loss surgery in Australia 2014–15: Australian hospital statistics
Weight loss surgery in Australia 2014–15: Australian hospital statistics is a new report in AIHW’s series of summary reports describing the characteristics of hospitals and hospital services in Australia. In 2014–15, there were about 22,700 hospital separations involving one or more weight loss surgery procedures. Seven in 8 of these separations occurred in private hospitals. Around 18,000 of weight loss surgery separations, or 79%, were for female patients. From 2005–06 to 2014–15, the total number of weight loss surgery separations more than doubled, from about 9,300 to 22,700.
Admitted patient care 2015–16: Australian hospital statistics
In 2015–16, there were about 10.6 million separations in Australia’s public and private hospitals—about 59% occurred in public hospitals. There were 30 million days of patient care reported for admitted patients—20.2 million in public hospitals and 9.7 million in private hospitals. Between 2011–12 and 2015–16: the number of separations rose by 3.5% on average each year; the number of public patient separations rose by an average of 2.9% each year, compared with 5.5% per year for separations paid for by private health insurance; the median waiting time for elective surgery for public patients in a public hospital was 42 days, while it was 20 days for patients who used private health insurance to fund all or part of their admission.