more_vertTelling parents that their child has congenital heart disease and needs heart surgery is a difficult task. Parents will rightly ask what is the risk for my child, what are a particular hospital’s or an individual surgeon’s outcome statistics, and which hospital should they choose. As a result of the Bristol Inquiry in 2001, which was initiated following an unusually high mortality rate at the Bristol Royal Infirmary, the UK has been at the forefront of publishing these individual statistics, and since 2013, 30-day survival rates after heart surgery have been published for each hospital.
Preference: Surgery
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[Perspectives] John Keats: science and sympathy
According to his friend Charles Brown, John Keats (1795–1821) was “compelled, by conscientious motives” to abandon a career in medicine “upon discovering that he was unfit to perform a surgical operation. He ascribed his inability to an overwrought apprehension of every possible chance of doing evil in the wrong direction of the instrument.” Written 20 years after Keats’s death, Brown’s anecdote is a small but telling example of the posthumous (and inaccurate) presentation of the poet as a nervous and unworldly figure, too sensitive for the brutal realities of early 19th-century medicine, especially surgery without anaesthetics.
Private health insurance – its role in the Australian health system
Women with private health cover are overwhelmingly choosing to use the public health system for their second baby, Medibank Private chief medical officer Linda Swan told delegates at the AMA National Conference.
In a policy session on the role of private health insurance in the Australian health care system, Dr Swan said expenditure and claims were exceeding patients’ willingness to use their private cover.
“People are very clearly telling us that affordability is their No.1 issue,” Dr Swan said.
Rising health care costs could not continue unless Governments and consumers were willing to pay more, or the expense of care could be reduced, she said.
Earlier that day, News Corp national health reporter Sue Dunlevy told the conference that she had been “forced” by the Government to take out private health insurance but was “determined not to use it” because of excessive out-of-pocket expenses.
“There’s something crooked at the heart of the private health insurance industry in this country,” Ms Dunlevy said.
But Professor John Horvath, the strategic medical advisor at Ramsay Health Care, had a more positive view of the future.
“Australia has an excellent health care system producing world-leading outcomes for patients,” Professor Horvath said.
“Australia spends around 9 per cent of GDP on health care, of which 30 per cent is from private sources. This is lower than the OECD average, yet our life expectancy and outcomes are among the highest in the OECD.”
Professor Horvath said the ongoing increase in demand for health care, and rising costs, meant payers – including governments – and consumers would continue to push for more value from their health care spend.
He said benchmarked performance reporting and clinician engagement, not “stick” approached like financial penalties, would drive real improvements in quality, while digital technology would improve patient outcomes and enable hospitals to extend their care beyond hospital walls.
“This is all good news for patients,” he said.
Ramsay has begun measuring and benchmarking with the International Consortium on Health Outcomes Measurement (ICHOM) to allow global comparison of specific medical conditions.
It is measuring outcomes in six specific areas:
- Low back pain,
- Hip and knee osteoarthritis,
- Cataract surgery,
- Coronary artery disease,
- Depression and anxiety, and
- Prostate cancer.
The measurements will take in readmission rates, returns to theatre, infection rates, falls, hand hygiene, pressure injuries, medication safety, and patient experience.
Ramsay is also adding new measures including quality of life following treatment, survival, and disease control.
It is also about to commence a trial of the Vanderbilt Program, to assess its effectiveness in managing poorly behaved Visiting Medical Officers who undermine a culture of safety and quality.
The Vanderbilt Program looks at behaviours such as not following a surgical checklist, not washing hands, and bullying of staff – all of which can lead to consequences such as surgical complications, high rates of infections or errors, lawsuits, and loss of staff.
The program is based on the principal of having a conversation with a physician around their behaviour and building up to authority conversations with clearly defined consequences.
Opinions from the floor were mixed. Some doctors said that the combination of more complex patients, procedures and medications would inevitably lead to higher expenditures.
Others said that in most industries, new technologies drive costs down, but in health care they increase costs.
Maria Hawthorne
AMA Awards
President’s Award
Dr Paul Bauert OAM and Dr Graeme Killer AO
Two doctors, one a passionate advocate for the disadvantaged and the other a pioneering force in the care of military veterans, have been recognised with the prestigious AMA President’s Award for their outstanding contributions to the care of their fellow Australians.
Dr Paul Bauert, the Director of Paediatrics at Royal Darwin Hospital, has fought for better care for Indigenous Australians for more than 30 years. More recently, he has taken up the battle for children in immigration detention.
Dr Bauert arrived in Darwin in 1977 as an intern, intending to stay for a year or two. In his words: “I’m still here, still passionate about children’s health and what makes good health and good healthcare possible for all children and their families. I believe I may well have the best job on the planet.”
Dr Graeme Killer, a Vietnam veteran, spent 23 years in the RAAF before becoming principal medial adviser to the Department of Veterans’ Affairs. Over the next 25 years, he pioneered major improvements in the care of veterans, including the Coordinated Veterans’ Care project.
Dr Killer has overseen a series of ground-breaking research studies into the health of veterans, including Gulf War veterans, atomic blast veterans, submariners, and the F-111 Deseal and Reseal program. He was also instrumental in turning around the veterans’ health care system from earlier prejudicial attitudes towards psychological suffering.
Dr Bauert and Dr Killer were presented with their awards by outgoing AMA President, Professor Brian Owler, at the AMA National Conference Gala Dinner.
Excellence in Healthcare Award
The Excellence in Healthcare Award this year recognised a 20-year partnership devoted to advancing Aboriginal health in the Northern Territory.
Associate Professor John Boffa and Central Australian Aboriginal Congress CEO Donna Ah Chee were presented with the Award for their contribution to reducing harms of alcohol and improving early childhood outcomes for Aboriginal children.
Associate Professor Boffa has worked in Aboriginal primary care services for more than 25 years, and moved to the Northern Territory after graduating in medicine from Monash University.
As a GP and the Chief Medical Officer of Public Health at the Central Australian Aboriginal Congress, he has devoted his career to changing alcohol use patterns in Indigenous communities, with campaigns such as ‘Beat the Grog’ and ‘Thirsty Thursday’.
Ms Ah Chee grew up on the far north coast of New South Wales and moved to Alice Springs in 1987. With a firm belief that education is the key pathway to wellbeing and health, she is committed to eradicating the educational disadvantage afflicting Indigenous people.
Between them, the pair have initiated major and highly significant reforms in not only addressing alcohol and other drugs, but in collaborating and overcoming many cross-cultural sensitivities in working in Aboriginal health care.
Their service model on alcohol and drug treatment resulted in a major alcohol treatment service being funded within an Aboriginal community controlled health service.
AMA Woman in Medicine Award
An emergency physician whose pioneering work has led to significant reductions in staph infections in patients is the AMA Woman in Medicine Award recipient for 2016.
Associate Professor Diana Egerton-Warburton has made a major contribution to emergency medicine and public health through her work as Director of Emergency Research and Innovation at Monash Medical Centre Emergency Department, and as Adjunct Senior Lecturer at Monash University.
Her just say no to the just-in-case cannula has yielded real change in practice and has cut staff infections in patients, while her Enough is Enough: Emergency Department Clinicians Action on Reducing Alcohol Harm project developed a phone app that allows clinicians to identify hazardous drinkers and offer them a brief intervention and referral if required.
Associate Professor Egerton-Warburton has been passionate about tackling alcohol harm, from violence against medical staff in hospitals to domestic violence and street brawls.
She championed the first bi-annual meeting on public health and emergency medicine in Australia and established the Australasian College of Emergency Medicine’s alcohol harm in emergency departments program.
In addition, she has developed countless resources for emergency departments to facilitate management of pandemic influenza and heatwave health, and has authored more than 30 peer-reviewed publications.
Professor Owler said Associate Professor Egerton-Warburton’s tireless work striving for high standards in emergency departments for patients and her unrelenting passion to improve public health made her a deserving winner of the Award.
AMA Doctor in Training of the Year Award
Trainee neurosurgeon Dr Ruth Mitchell has been named the inaugural AMA Doctor in Training of the Year in recognition of her passion for tackling bullying and sexual harassment in the medical profession.
Dr Mitchell, who was a panellist in the Bullying and Harassment policy session at National Conference, is in her second year of her PhD at the University of Melbourne, and is a neurosurgery registrar at the Royal Melbourne Hospital.
Presenting the award, Professor Owler said Dr Mitchell had played a pivotal role in reducing workplace bullying and harassment in the medical profession and was a tireless advocate for doctors’ wellbeing and high quality care.
MJA/MDA National Prize for Excellence in Medical Research
A study examining the impact of a widely-criticised ABC TV documentary on statin use won the award for best research article published in the Medical Journal of Australia in 2015.
Researchers from the University of Sydney, University of NSW and Australian National University found that tens of thousands of Australians stopped or reduced their use of cholesterol-lowering drugs following the documentary’s airing, with potentially fatal consequences.
In 2013, the science program Catalyst aired a two-part series that described statins as “toxic” and suggested the link between cholesterol and heart disease was a myth.
The researchers found that in the eight months after program was broadcast, there were 504,180 fewer dispensings of statins, affecting more than 60,000 people and potentially leading to as many as 2900 preventable heart attacks and strokes.
AMA/ACOSH National Tobacco Scoreboard Award and Dirty Ashtray
The Commonwealth Government won the AMA/ACOSH National Tobacco Scoreboard Award for doing the most to combat smoking and tobacco use, while the Northern Territory Government won the Dirty Ashtray Award for doing the least.
The Commonwealth was commended for its continuing commitment to tobacco control, including plain packaging and excise increases, but still only received a B grade for its efforts.
The Northern Territory received an E grade for lagging behind all other jurisdictions in banning smoking from pubs, clubs, and dining areas, and for a lack of action on education programs.
State Media Awards
Best Lobby Campaign
AMA NSW won the Best Lobby Campaign award for its long-running campaign to improve clinician engagement in public hospitals.
The campaign started after the Garling Inquiry in 2008, which identified the breakdown of trust between public hospital doctors and their managers as an impediment to good, safe patient care.
It led to a world-first agreement between the NSW Government and doctors, signed in February 2015 by Health Minister Jillian Skinner, AMA NSW and the Australian Salaried Medical Officers’ Federation NSW, to embed clinician engagement in the culture of the public hospital system, and to formally measure how well doctors are engaged in the decision-making processes.
Best Public Health Campaign
AMA NSW also took home the Best Public Health Campaign award for its innovative education campaign on sunscreen use and storage.
The campaign drew on new research which found that many Australians do not realise that sunscreen can lose up to 40 per cent of its effectiveness if exposed to temperatures above 25 degrees Celsius.
The campaign received an unexpected boost with the release of survey results showing that one in three medical students admitted to sunbaking to tan, despite knowing the cancer risk.
Best State Publication
AMA WA won the highly competitive Best State Publication award for its revamped Medicus members’ magazine.
The 80-page publication provides a mix of special features, clinical commentaries, cover articles and opinion pieces to reflect the concerns and interests of WA’s medical community and beyond.
The judges said that with its eye-catching covers, Medicus made an immediate impact on readers.
Most Innovative Use of Website or New Media
AMA WA won the award for its Buildit portal, a mechanism for matching trainee doctors with research projects and supervisors.
The judges described Buildit as taking the DNA of a dating app and applying it to the functional research requirements of doctors in training, allowing for opportunities that may have otherwise been missed.
National Advocacy Award
AMA Victoria won the National Advocacy Award for its courage and tenacity in tackling bullying, discrimination and harassment within the medical profession.
AMA Victoria sought the views and concerns of its members, and made submissions to both the Royal Australasian College of Surgeons’ inquiry and the Victorian Auditor-General’s audit of bullying, harassment and discrimination within state public hospitals.
The judges said that tackling a challenge within your own profession was a particularly difficult task, especially in the glare of public scrutiny, making the AMA Victoria campaign a standout.
Maria Hawthorne
News briefs
Wearable sensor measures fitness levels, heart function
Researchers from the University of California-San Diego in the US have developed a wearable patch that can measure biochemical and electrical signals in the human body simultaneously, reports Medical News Today. “The device — called the Chem-Phys patch — measures real-time levels of lactate, an indicator of physical activity, as well as the heart’s electrical activity. Put simply, the novel technology monitors a person’s fitness levels and heart function at the same time, and it is the first device that can do so. The patch is made of a thin, adhesive, flexible sheet of polyester, which the researchers manufactured using screen printing. A lactate-sensing electrode is situated in the centre of the patch, and two electrocardiogram electrodes are situated either side. The researchers found that the data collected by the EKG electrodes closely matched the data collected by a commercial heart rate monitor. Furthermore, they found that the information gathered by the lactate sensor closely matched lactate data collected during increasing physical activity in previous studies.”
http://www.nature.com/ncomms/2016/160523/ncomms11650/full/ncomms11650.html
Obesity linked to lower quality of nursing home care
US researchers have found that nursing homes that admitted more morbidly obese residents were also more likely to have more severe deficiencies in care, according to a study published in the Journal of the American Geriatrics Society. Science Daily reports that the study was designed to find out “whether obese older adults were as likely as non-obese elders to be admitted to nursing homes that provided an appropriate level of care”. “The researchers examined 164 256 records of obese people aged 65 or older who were admitted to nursing homes over a 2-year period. They also examined the nursing homes’ total number of deficiency citations and quality-of-care deficiencies to determine the quality of care that the homes provided. The researchers reported that about 22% of older adults admitted to nursing homes were obese. Nearly 4% were considered morbidly obese. Nursing homes that admitted a higher number of obese residents were more likely to have a higher number of deficiencies.”
https://www.sciencedaily.com/releases/2016/05/160531182543.htm
Australians among world’s longest-living: WHO
A new report from the World Health Organization says there have been gains in global life expectancy since 2000, with the overall increase of 5 years to a tick over 71 years the fastest rise since the 1960s, and reverses the declines seen in the 1990s. The World health statistics 2016: monitoring health for the Sustainable Development Goals (SDGs) report shows that the greatest increase in life expectancy during 2000–2015 has been in the African region, where it rose from 9.4 years to 60 years, due to reduction in child deaths, progress in malaria control, and better access to HIV antiretrovirals. Globally, the average lifespan of a child born in 2015 is likely to be 71.4 years — or 73.8 years if it is a girl and 69.1 years if it is a boy. The longest life expectancy is in Japan, where children born in 2015 are expected to live 83.7 years, followed by Switzerland (83.4 years), Singapore (83.1 years), Australia (82.8 years), and Spain (82.8 years). Average life expectancy for the United States is 79.3 years. The report also quantifies the causes of death and ill-health that pose significant challenges in meeting the SDGs.
http://www.who.int/gho/publications/world_health_statistics/2016/en/
Beware barbecue brush bristles
Research published in Otolaryngology — Head and Neck Surgery has investigated the epidemiology of wire-bristle barbecue brush injuries. Between 2002–2014, more than 1600 emergency department visits occurred as a result of wire-bristle brush injuries in the US, some of them requiring surgery. According to Medical News Today: “While wire grill brushes may be an effective cleaning tool prior to or following a cookout, the bristles can easily fall off and make their way into people’s food. If ingested, these little strands of metal can cause some serious injuries to the mouth, throat, and gastrointestinal region. The researchers hope their findings will promote greater awareness among manufacturers, consumers, and healthcare providers of the potential health hazards associated with wire-bristle brushes.”
Effect of surgical safety checklists on pediatric surgical complications in Ontario [Research]
Background:
In health care, most preventable adverse events occur in the operating room. Surgical safety checklists have become a standard of care for safe operating room practice, but there is conflicting evidence for the effectiveness of checklists to improve perioperative outcomes in some populations. Our objective was to determine whether surgical safety checklists are associated with a reduction in the proportion of children who had perioperative complications.
Methods:
We conducted a retrospective cohort study using administrative health care databases housed at the Institute for Clinical Evaluative Sciences to compare the risk of perioperative complications in children undergoing common types of surgery before and after the mandated implementation of surgical safety checklists in 116 acute care hospitals in Ontario. The primary outcome was a composite outcome of 30-day all-cause mortality and perioperative complications.
Results:
We identified 14 458 and 14 314 surgical procedures in pre- and postchecklist groups, respectively. The proportion of children who had perioperative complications was 4.08% (95% confidence interval [CI] 3.76%–4.40%) before the implementation of the checklist and 4.12% (95% CI 3.80%–4.45%) after implementation. After we adjusted for confounding factors, we found no significant difference in the odds of perioperative complications after the introduction of surgical safety checklists (adjusted odds ratio 1.01, 95% CI 0.90–1.14, p = 0.9).
Interpretation:
The implementation of surgical safety checklists for pediatric surgery in Ontario was not associated with a reduction in the proportion of children who had perioperative complications.
Trial registration:
ClinicalTrials.gov, no. NCT02419053
[Clinical Picture] Embolic central retinal artery occlusion after subcutaneous auricular steroid injection
A healthy 12-year-old boy had a subcutaneous triamcinolone acetonide steroid injection at the site of a keloid on his left earlobe in November, 2008, at a plastic surgery clinic. Within 5 min, he developed left-sided facial numbness, diaphoresis, dizziness, hypaesthesia of the left side of the mouth and tongue, left upper lid ptosis, and nearly complete vision loss in his left eye. Several hours later his systemic symptoms had resolved, he had regained partial vision in his left eye, and his right eye was asymptomatic.
[Articles] Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis
TAVR with SAPIEN 3 in intermediate-risk patients with severe aortic stenosis is associated with low mortality, strokes, and regurgitation at 1 year. The propensity score analysis indicates a significant superiority for our composite outcome with TAVR compared with surgery, suggesting that TAVR might be the preferred treatment alternative in intermediate-risk patients.
[Comment] All over for valve surgery for intermediate-risk patients?
Based on the findings of three randomised trials1–3 transcatheter aortic valve replacement (TAVR) is now first-line therapy in patients with severe aortic stenosis who are at high risk or are unsuitable for surgery.4,5 As a consequence of rapid refinements of devices and procedure techniques there is a trend to extend TAVR to lower-risk patients. This trend has been encouraged by small propensity-matched studies and a small randomised trial in intermediate-risk and lower-risk patients, which showed favourable results compared with surgery.
[Review] Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities, 3rd edition
Investments in cancer control—prevention, detection, diagnosis, surgery, other treatment, and palliative care—are increasingly needed in low-income and particularly in middle-income countries, where most of the world’s cancer deaths occur without treatment or palliation. To help countries expand locally appropriate services, Cancer (the third volume of nine in Disease Control Priorities, 3rd edition) developed an essential package of potentially cost-effective measures for countries to consider and adapt.