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Preference: Surgery

1175

New surgical technology: do we know what we are doing?

How can we best protect patients while making progress?

The pace of development in new surgical procedures and technologies continues to accelerate, driven in part by manufacturers, surgeons and community expectations. Despite regulatory bodies such as the Therapeutic Goods Administration (TGA), new devices can enter the market with little or no evidence of their effectiveness, and even their safety can be poorly evaluated. The withdrawal of the DePuy Orthopaedics articular surface replacement hip prosthesis illustrates the difficulty in anticipating the unintended problems with a joint prosthesis that superficially appeared to be little different from hundreds of others already available on the market.1

Innovation is not well regulated

While the TGA attempts to assess devices, the evidence base necessary for determining their durability in human use is rarely available or is inadequate. The introduction of new procedures is even less regulated. If a completely new procedure is developed and a Medicare item number is sought, then the Medical Services Advisory Committee2 would usually assess its merits; however, this is not required in the public health system.

Of greater concern is the ability to use existing Medicare descriptors to cover new procedures. This occurred with the introduction of laparoscopic cholecystectomy in 1991 and enabled an untested new procedure to be introduced without approval, oversight or training. The subsequent outcry prompted the federal government, in partnership with the Royal Australasian College of Surgeons, to establish the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) to evaluate the evidence for new devices or procedures and to report to surgeons, patients, government and hospitals on their evidence base and training implications.3

In 2006, ASERNIP-S evaluated three endoscopic antireflux procedures and found that evidence to support their use was lacking. Despite this, they were taken up by enthusiastic practitioners — surgeons as well as gastroenterologists. They have now completely disappeared from practice. Few reports of their failure have appeared, yet thousands of patients were subjected to these now-abandoned interventions.4

In recent years, hospitals have started to play a greater role in credentialling surgeons for procedures, and committees often exist to evaluate new procedures that are introduced into a health care facility. While an admirable principle, the practice is often flawed. New surgical approaches using existing technologies, such as laparoscopic hernia repair or laparoscopic liver resection, can be introduced into operating theatres at the discretion of the surgeon. Unless the ethical imperative to notify the institution is clear and policed, this practice may continue.

The introduction of robotic-assisted surgery for prostate operations has been widely debated.5 However, the same discussion and rigour has not been applied to robotic assistance in ear, nose and throat, gynaecological and colorectal surgery. Indeed, it is even now being used in thyroid surgery with limited evidence.6

The IDEAL recommendations

The problem of the introduction of new surgical technology and procedures has been addressed by the IDEAL recommendations.7 This concept does not view surgical development as different from non-surgical advances. The recommendations involve suggestions for the five stages of evaluating new surgical procedures — innovation, development, exploration, assessment and long-term (or surveillance) stages. Innovation will apply to interventions such as stem cell-based tracheal transplantation for tracheal stenosis.8 Exploration may apply to single-incision laparoscopy, with long-term studies being directed at procedures such as surgery for morbid obesity.8

IDEAL encourages full reporting and staged introduction of new surgical technologies so that the disasters of the past can be avoided and new lessons can be learnt quickly and disseminated. Prospective databases and registries for new procedures and techniques will allow monitoring of early as well as late and rare outcomes.

Patients are vital to progress

It is difficult for patients to provide full and informed consent for a new or innovative procedure, as results and outcomes are lacking. Preferably, the effectiveness of such uncertain new interventions would be established through ethically constructed and approved trials from which, hopefully, outcome data would be reported to the wider medical community. The participation of patients who have undergone a full and informed consent process is vital to making progress with surgical improvements and breakthroughs.

However, individual practitioners’ enthusiasm for or belief in a new operation should not expose patients to oversold, poorly evaluated interventions. Surgical randomised controlled trials are difficult to perform, but they are possible. There are very few examples of operations that cannot be carefully evaluated following the IDEAL recommendations.9 Usually, there are alternative established approaches that provide other avenues for patients who are unwilling to be included in research studies.

Surgeons have a responsibility to innovate, stay up-to-date and retrain, primarily for the benefit of their patients. Guidelines, processes and regulations exist and should be embraced. Do we really know the place of innovative technologies and practices that are already in use — for example, duodenal sleeve technology,10 peritonectomy,11 robotic thyroid surgery5 or mitral clip technology?12 If not, how carefully and ethically are they being introduced into mainstream practice?

Cataract surgical blitzes: an Australian anachronism

Surgical blitzes may achieve short-term gains, but they inhibit the development of sustainable local services

Surgical blitzes to treat eye disease are often used to redress shortfalls in service provision. In developing countries with scarce human and financial resources, such periodic visits from local or overseas health teams may be justified, as they are generally combined with building local capacity. However, Australia has no such resource constraints. Despite this, surgical blitzes occur year after year in some rural and remote locations in Australia, without concurrent development of sustainable local services. We see this as a particular problem for eye health in Indigenous people.

The first eye surgical blitzes in Australia occurred during the National Trachoma and Eye Health Program in the 1970s. At each site, an Australian Army field hospital team worked for a week, and about a hundred Aboriginal people had sight-restoring eye surgery.1 Over the years, similar army exercises were repeated across the Northern Territory, including, on one occasion, a tented field hospital being put up in a hospital car park.2

Everyone felt a very good job was being done, but nothing really changed. More recently, regular surgical blitzes, rebranded as “surgical intensives”, were started in Alice Springs and elsewhere in the NT; but these were also short-term fixes.

There is an ongoing need for more eye surgery in these areas.3 Aboriginal and Torres Strait Islander people have a sixfold greater rate of blindness than non-Indigenous Australians.4 They have 12 times higher rates of cataract blindness, but receive seven times less cataract surgery. A blind Indigenous person needing cataract surgery should be put on a surgical waiting list and operated on within 3 months.5 However, those who manage to get onto a waiting list will wait almost twice as long as non-Indigenous Australians,6 sometimes waiting several years or more before receiving surgery.

There are complex factors affecting Indigenous Australians’ willingness to attend for surgical treatment, but once a patient is ready for surgery, he or she should receive it promptly. Surgery may need to be delivered opportunistically for patients with competing community and cultural priorities. Multiple things can be done to prevent Indigenous patients from dropping out of the system: 35 such key points have been identified in the patient journey for cataract surgery.7

Blitzes seem to provide a quick and rewarding solution. Surgery gets done, patients get their vision back, and surgeons and staff feel satisfied. Blitzes usually receive government and private funding, so the investors feel good that something is being done and they obtain positive publicity. But the patients who turn up the next week do not feel so good. They do not know how long they will have to stay blind while awaiting another blitz. Those who were already on a waiting list but could not forgo family, community or cultural responsibilities for the surgery have to wait longer. The staff who worked so hard to make the blitz possible understandably need a break; until it is time to start planning the next one. The end result is that the system is never fixed and rolling blitzes become the norm in dealing with the aching unmet need.

Although there is still a long way to go, Indigenous life expectancy is improving. With an ageing population, the burden of age-related cataract is likely to double in the next 20 years,8,9 and an increasing number of older Indigenous Australians will need sight-restoring cataract surgery. We must ensure that Indigenous people do not experience unnecessarily prolonged visual impairment and blindness, to enable them to maintain quality of life and independence in these additional years of life.10 While poor vision is not the only unsolved problem in Indigenous health, it causes 11% of the health gap.11 Unlike many other conditions, most of this vision loss can be cured overnight with spectacles or cataract surgery.

What is required is adequate provision of sustainable, ongoing services.12 Surgical blitzes on their own are neither a long-term nor a sustainable solution. They may show what is possible with adequate resources over the short term, but no lasting change is implemented and the underresourced local service struggles on. Blitzes alone will not clear the growing backlog or provide sufficient volume of services to meet the increasing need for surgery; although targeted blitzes to clear a regional backlog, with concurrent development of ongoing coordinated surgical services, make sense.13 With the backlog reduced, the local service then requires appropriate resourcing to meet the ongoing need for surgery in a timely manner and to provide the direct personal interaction that is so highly valued by the Indigenous community and patients.

Unfortunately, despite the best of intentions and attempts at gaining government commitment through agreements and memoranda of understanding, the diversion of resources to arranging surgical blitzes means there are limited resources allocated to developing local services. So, paradoxically, blitzes prevent the development of the sustainable solutions needed to provide equity of care and to close the gap in Indigenous eye health.

Australia in 2015 has a sophisticated health system with the capacity to provide the services required. We cannot afford repeated short-term and unsustainable surgical blitzes. We are lucky that strong advocacy exists among vision care organisations to raise awareness of the need for long-term solutions and sustainable regional eye services.14 Australia should be leading the way in showing how to deliver eye care, rather than consistently showing how not to.

Priorities for professionalism: what do surgeons think?

Professionalism underpins the commitment made between a profession and society. This social contract balances the benefit to a profession of a monopoly over the use of its knowledge base, its right to considerable autonomy of practice, and the privilege of self-regulation with responsibilities and accountabilities to the community.

Medical practitioners have embraced professionalism over the millennia, from the Hippocratic Oath1 to the 19th century2 and the present day. Professionalism has recently been highlighted,3 but there have been concerns that not all its components are viewed as important4,5 or are reflected appropriately in surgical training endeavours.6

Definitions of professionalism are abundant, contested and reflect educational, sociocultural and historical contexts.7,8 Core elements include mastery of a complex body of knowledge and skills, service to others, commitment to competence, integrity, altruism and promotion of public good, autonomy, self-regulation and accountability to society.9 Given the dynamic and changing context, it is important to understand how professionalism is evolving.

Little is currently known about how surgeons involved in training and surgical trainees perceive the importance, priority or value of the different areas that they need to master to be competent and to perform well. In Australia and New Zealand, the Royal Australasian College of Surgeons (RACS) has defined the competencies required for surgical practice. The RACS surgical competence and performance guide is the basis of the curriculum that leads to the Fellowship of the College.10 It is based on the competencies developed by the Royal College of Physicians and Surgeons of Canada — the CanMEDS model.11 Local adaptation since 2001 has seen the RACS develop nine competencies to reflect the technical expertise and decision making required in surgical practice. Three attributes per competence provide further detail, although not comprehensiveness, to the overall requirements. Given the broad and changing definitions of professionalism, we evaluated the RACS competencies and associated attributes for importance.

Our study explored systematically what surgeons and surgical trainees understand as priorities for competent professional practice. It was undertaken within the broader context of developing system-wide training programs to enable surgeons to demonstrate their professionalism more fully.

Methods

Ethics approval for the study was obtained from the human research ethics committees of the University of Melbourne and the RACS. The overall research design included a detailed questionnaire comprising a number of question banks, with some free-text fields, distributed to 3054 RACS trainees and Fellows who were actively involved in the educational activities of the College. Separately and consequently, a semistructured interview was undertaken with a smaller number of the questionnaire respondents who volunteered for the interview stage. This article relates to the bank of RACS competency questions.

Participants

At the time of the distribution of the questionnaire, from 9 August to 30 September 2010, there were 1222 trainees and 4763 actively practising Fellows within the RACS. All trainees were invited to complete the questionnaire, and all Fellows recorded in the membership database as being involved in educational activities were also selected. Fellows who were not involved in surgical educational activities did not receive a questionnaire. The final number invited was 1222 trainees and 1832 Fellows from all regions of Australia and New Zealand. Although all questionnaires were identified with a unique identifier to allow for follow-up, anonymity and confidentiality were assured.

Materials and procedures

The questionnaire incorporated the nine RACS competencies and the associated three attributes per competency (Box 1), with modification for brevity and clarity. The questionnaire was content valid as it was directly based on the established RACS competency framework. Within the questionnaire, all participants were informed that the intent of the research was to progress the understanding of professionalism and the way it is supported, taught and learnt. Participants were instructed to rate the importance of each attribute for professionals on a 5-point Likert scale (1 = not at all important, 5 = very important).

The questionnaire was disseminated electronically with a follow-up email. A hard copy of the questionnaire was sent to those who had not responded and was then followed up by a telephone call.

Statistical analysis

Neither the nine competencies nor the 27 attributes have previously been confirmed statistically as independent factors. Analysis was undertaken to compare the importance of the attributes at an individual and grouped level, and to determine whether they were independent and whether the RACS groupings were confirmed by the data.

The data were coded and entered into SPSS version 17 (SPSS Inc). We also applied tests of skewness and kurtosis.12 Because of the skewed nature of the data, we conducted non-parametric statistical tests to analyse subgroups: the Mann–Whitney U test for pair comparisons and the Kruskal–Wallis test for comparison of more than two groups. The results for all attributes were assessed within their respective competencies to gain a relative understanding of the importance of that competency. Comparisons were made between Fellow and trainee, genders, age groups, specialties and regions. In this article, we present our findings for Fellows and trainees, and by gender.

We also applied tests of reliability, with internal consistency being calculated through use of Cronbach α value (theoretical values between 0 and 1). Inferential statistics were then used to identify differences between groups and to look for relationships between attributes. Groups for comparison had a sample size greater than 100. Correlation studies were structured to investigate relationships between particular characteristics of the subgroups.

We undertook multivariate analysis to establish the independence of the variables and also to determine whether the groupings of attributes proposed by the RACS within the competency framework could be validated in the context of our questionnaire. The exploratory factor analysis used an extraction method of unweighted least squares.

Results

In total, 1834 of 3054 questionnaires were returned (60%): 1204 of 1832 Fellows (66%) and 630 of 1222 trainees (52%); 1521 of 2566 (59%) male and 313 of 488 (64%) female trainees and Fellows. Seven hundred and nine (39%) responses were from general surgery Fellows and trainees and 357 (19%) were from orthopaedic surgery Fellows and trainees, the largest two of the nine surgical specialties.

The results were skewed to the more important. This was confirmed by tests for both skewness and kurtosis, both of which were evident to a high degree. Testing of reliability was undertaken, with a resultant Cronbach α value of 0.971.

The 27 attributes identified by the RACS were all graded as individual attributes (Box 2) or grouped as competencies (Appendix 1). They were all regarded as important to very important, except for responding to community and cultural needs. The top five attributes shared a sense of strong individualism, with an emphasis on being able to communicate effectively. However, there was a clear gap to the more lowly ranked attributes, particularly responding to community and cultural needs, and supporting others.

We calculated differences in the mean ranking of importance for the 27 attributes (Box 2, Appendix 2, Appendix 3). The overall mean was 4.44 (4 = important, 5 = very important). There was a small but significant difference between genders, with women regarding the overall group of attributes as more important than did men (mean, 4.51 [SD, 0.37] v 4.43 [SD 0.37]; P = 0.001) There was no statistically significant difference between Fellows and trainees for the overall group of attributes (mean, 4.44 [SD, 0.41] v 4.44 [SD, 0.40], respectively; P = 0.99).

Competencies were ranked by priority for Fellows and trainees, and for males and females (Box 3). There was consistency in the top three priorities for Fellows and trainees overall, and for male Fellows and trainees, where technical expertise, communication and professionalism were prioritised. For female Fellows and trainees, the top three priorities were communication, technical expertise and medical expertise. The lowest priorities across all groups were health advocacy, management and leadership, and scholarship and teaching.

Among individual attributes, there were statistically significant differences in perceived importance at the subgroup level (Appendix 2). In comparing Fellows and trainees, the four attributes with statistically more significant differences were caring and compassion, documenting and exchanging information, setting and maintaining standards, and responding to community and cultural needs. In particular, trainees identified as more important the three attributes for collaboration and teamwork (teamwork, documenting and exchanging information, and establishing a shared understanding).

In our analysis by gender, female trainees and Fellows ranked all attributes as more important than did male trainees and Fellows. Statistical significance was most noted for teamwork, meeting patient, carer and family needs, documenting and exchanging information, establishing a shared understanding, and communicating effectively (Appendix 3).

Although the first nine factors identified through multivariate analysis accounted for 58.8% of the total variation in the data, further analysis did not demonstrate strong grouping to the nine categories. Indeed, the covariance values of six attributes exceeded 1.0, suggesting some overlap between the groupings. Also, as the Cronbach α value was high at 0.971, some redundancy in the items was indicated statistically.

Discussion

Our study looked at the breadth of professionalism among surgeons and surgical trainees by exploring the nine competencies defined by the RACS. Our findings confirmed a clear priority ranking for these competencies and their attributes.

All competencies were regarded as important; however, there were statistically significant differences between the nine competencies and 27 attributes. Although the multivariate analysis did not confirm the independent nature of these variables, there was a clear gap between the prioritised importance of technical expertise, communication, professionalism and medical expertise compared with health advocacy, and management and leadership. Our findings suggest an emphasis on individual skills rather than on achieving a common goal. Attributes relating more to society at large were prioritised less than individualised skills. Also important was the strong similarity between the responses of the trainees and Fellows who undertake educational roles on behalf of the RACS. This may indicate the socialisation of aspirations between trainees and their mentors and educators.

Similar studies have emphasised that values held in high regard by society, such as altruism, charity and communication, are not well appreciated.6,13 Another study, which also found that none of the factors of professionalism were regarded as unimportant, argued that this added little to the broader issue of the teaching of professionalism.14 However, we contend that the prioritisation does make a difference. In a conflicted and time-pressured professional existence, a higher priority will receive attention for training and learning compared with a lower priority. The nine competencies defined by the RACS reflect what every patient needs from a competent surgeon.11 Surgeons require expertise in each of these competencies, but it is the integration of all these attributes that will make a competent surgeon. In a health environment where collaboration and teamwork is regarded increasingly as a core skill, and where the ability to influence the health system through management, leadership and advocacy is becoming more desirable, these areas will require greater prioritisation among trainees and Fellows.

Skills such as teamwork and responding to the needs of the community involve complex interactions beyond individual excellence. Medical professionalism does not take place in a vacuum. It is situated within a social context and larger systems such as the education and health sectors, the national economy and broader international influences.8 The practice of medicine needs to be rethought more broadly.

Our study had some limitations. Surveys are limited in the information they provide. The study confirmed the importance of the attributes and their relative priorities but not the statistical independence of the nine competencies. Further qualitative studies are required to obtain greater clarity between the attributes.

With the exception of responding to community and cultural needs, we found that all RACS competencies and attributes were regarded as important. The priorities showed consistency across Fellows, trainees and genders, although there were some key statistically significant differences between the attributes. This may highlight gaps that need to be addressed in selection of trainees, in current surgical training and in ongoing professional development for surgeons. Certainly these areas need to be addressed urgently.5 Attributes, behaviours, judgement and skills are displayed as our professionalism in a complex and pressured working environment that demands prioritisation of activities. These priorities are also reflected in how trainees allocate their time, through the mentors they admire and the aspirations they develop. Professionally, well-rounded and truly competent surgeons are not a static phenomenon. We live in a complex world. The implications are clear: aspiring surgeons are likely to invest more in the development of competencies that they perceive as more important.15 Competencies that are not reinforced by educators, mentors, trainers and the broader peer group are more likely to be neglected, with possible detriment to clinical practice.16

1 The nine Royal Australasian College of Surgeons competencies and their attributes10

Competency and attributes

Description

Medical expertise

  

Competence

Mastering and maintaining current knowledge and skills

Managing safety and risk

Ensuring patient safety by understanding and managing clinical risk

Monitoring and evaluating care

Regularly reviewing and evaluating clinical practice

Judgement and decision making

  

Considering options

Generating alternative possibilities and assessing them

Planning ahead

Predicting what might happen due to action or non-action

Implementing and reviewing decisions

Undertaking chosen action but reviewing its suitability

Health advocacy

  

Caring and compassion

A sympathetic consciousness of another’s distress

Meeting patient, carer and family needs

Engaging them in planning and decision making

Responding to community and cultural needs

Demonstrating the impact of culture and spirituality, and considering community needs

Technical expertise

  

Recognising conditions amenable to surgery

Understanding when intervention is or is not indicated

Maintaining dexterity and technical skills

Demonstrating sound surgical skills

Defining scope of practice

Undertaking surgery appropriate to training, expertise and surroundings

Professionalism

  

Insight

Self-awareness, the ability to recognise and understand one’s actions

Morality and ethics

Acting for the public good

Maintaining personal health and wellbeing

Particularly if it impacts on colleagues and team members

Communication

  

Discussing and communicating options

Communicating clearly with patients

Communicating effectively

With patient, family and team

Gathering and understanding information

Seeking timely and accurate information

Collaboration and teamwork

  

Teamwork

Ability to recognise and respect the expertise of others and work with them

Documenting and exchanging information

Ensuring a shared understanding among team members

Establishing a shared understanding

All relevant clinical information is understood by team

Management and leadership

  

Setting and maintaining standards

Supporting safety and quality by adhering to acceptable principles of surgery

Leading that inspires others

Appropriate mixture of both calm demeanour yet clear decision making

Supporting others

Providing cognitive and emotional help to team members

Scholarship and teaching

  

Improving surgical practice

Evaluating surgical practice and identifying opportunities for improvement

Showing commitment to lifelong and reflective learning

Through own learning

Teaching, supervision and assessment

Facilitating education of students, patients and colleagues

2 Overall ranking of importance of attributes defined in the Royal Australasian College of Surgeons surgical competence and performance guide*

Overall ranking of attributes from most to least important

Sample size

Mean (SD)

Median (IQR)

Competence

1818

4.77 (0.44)

5 (0)

Insight

1817

4.75 (0.46)

5 (0)

Recognising conditions amenable to surgery

1806

4.75 (0.45)

5 (0)

Discussing and communicating options

1807

4.60 (0.53)

5 (1)

Morality and ethics

1814

4.59 (0.59)

5 (1)

Communicating effectively

1806

4.58 (0.54)

5 (1)

Caring and compassion

1813

4.55 (0.58)

5 (1)

Teamwork

1813

4.54 (0.58)

5 (1)

Maintaining dexterity and technical skills

1806

4.53 (0.57)

5 (1)

Setting and maintaining standards

1806

4.51 (0.59)

5 (1)

Gathering and understanding information

1800

4.47 (0.56)

5 (1)

Considering options

1802

4.47 (0.57)

5 (1)

Managing safety and risk

1805

4.44 (0.61)

5 (1)

Improving surgical practice

1804

4.43 (0.61)

4 (1)

Defining scope of practice

1806

4.43 (0.66)

5 (1)

Planning ahead

1807

4.42 (0.62)

4 (1)

Showing commitment to lifelong and reflective learning

1808

4.39 (0.62)

4 (1)

Monitoring and evaluating care

1809

4.37 (0.62)

4 (1)

Documenting and exchanging information

1804

4.36 (0.62)

4 (1)

Leading that inspires others

1806

4.36 (0.64)

4 (1)

Teaching, supervision and assessment

1806

4.34 (0.63)

4 (1)

Establishing a shared understanding

1806

4.33 (0.62)

4 (1)

Implementing and reviewing decisions

1805

4.31 (0.62)

4 (1)

Meeting patient, carer and family needs

1805

4.31 (0.63)

4 (1)

Maintaining personal health and wellbeing

1796

4.28 (0.70)

4 (1)

Supporting others

1806

4.15 (0.71)

4 (1)

Responding to community and cultural needs

1804

3.86 (0.83)

4 (1)

IQR = interquartile range. * 5-point Likert scale:  1 = not at all important, 2 = not important, 3 = somewhat important, 4 = important, 5 = very important.

3 Importance of the Royal Australasian College of Surgeons competencies10*

 

Overall

Fellow

Trainee

Male

Female

Competency

No. of responses

Mean (SD)

Median (IQR)

No. of responses

Mean (SD)

Median (IQR)

No. of responses

Mean (SD)

Median (IQR)

No. of responses

Mean (SD)

Median (IQR)

No. of responses

Mean (SD)

Median (IQR)

Medical expertise

5432

4.53 (0.59)

5 (1)

3573

4.59 (0.59)

5 (1)

1859

4.51 (0.59)

5 (1)

4506

4.51 (0.59)

5 (1)

926

4.59 (0.56)

5 (1)

Judgement and decision making

5414

4.40 (0.61)

4 (1)

3561

4.39 (0.62)

4 (1)

1853

4.42 (0.59)

4 (1)

4489

4.39 (0.61)

4 (1)

925

4.48 (0.59)

5 (1)

Health advocacy

5423

4.24 (0.75)

4 (1)

3567

4.24 (0.76)

4 (1)

1856

4.23 (0.72)

4 (1)

4499

4.22 (0.76)

4 (1)

924

4.43 (0.70)

4 (1)

Technical expertise

5418

4.57 (0.58)

5 (1)

3561

4.57 (0.59)

5 (1)

1857

4.57 (0.56)

5 (1)

4492

4.56 (0.59)

5 (1)

926

4.63 (0.54)

5 (1)

Professionalism

5427

4.54 (0.62)

5 (1)

3573

4.55 (0.62)

5 (1)

1854

4.53 (0.61)

5 (1)

4508

4.53 (0.62)

5 (1)

919

4.57 (0.61)

5 (1)

Communication

5413

4.55 (0.55)

5 (1)

3560

4.56 (0.55)

5 (1)

1853

4.54 (0.54)

5 (1)

4490

4.53 (0.55)

5 (1)

923

4.64 (0.51)

5 (1)

Collaboration and teamwork

5423

4.41 (0.61)

4 (1)

3567

4.38 (0.62)

4 (1)

1856

4.46 (0.59)

5 (1)

4498

4.38 (0.62)

4 (1)

925

4.54 (0.56)

5 (1)

Management and leadership

5418

4.34 (0.67)

4 (1)

3565

4.33 (0.68)

4 (1)

1853

4.35 (0.64)

4 (1)

4495

4.33 (0.67)

4 (1)

923

4.41 (0.63)

4 (1)

Scholarship and teaching

5418

4.39 (0.62)

4 (1)

3566

4.39 (0.62)

4 (1)

1852

4.38 (0.62)

4 (1)

4494

4.39 (0.62)

4 (1)

924

4.40 (0.62)

4 (1)

Total

48 786

4.44 (0.63)

5 (1)

32 093

4.44 (0.64)

5 (1)

16 693

4.44 (0.62)

5 (1)

40 471

4.43 (0.64)

5 (1)

8315

4.51 (0.60)

5 (1)

IQR = interquartile range. * 5-point Likert scale: 1 = not at all important, 2 = not important, 3 = somewhat important, 4 = important, 5 = very important.

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Medics to fix ‘fear’ culture, The Daily Telegraph, 4 April 2015

A change in the way doctors and nurses report abuse is needed to buck the scourge of sexual harassment and protect whistleblowers within the medical industry. AMA President A/Professor Brian Owler was committed to bringing about cultural change within the profession.

$8.40 more to see doctor, Herald Sun, 7 April 2015

Patients could be paying up to $8.40 for a visit to the doctor by 2018, more than they would have paid under the GP co-payment. AMA President A/Professor Brian Owler said the lazy policy would mean fewer patients would be offered bulk-billing.

Religious belief saw mum and baby die, The Daily Telegraph, 8 April 2015

The AMA has defended doctors at a top Sydney hospital forced to let a heavily pregnant woman and her unborn child die after the mother refused a blood transfusion because she was a Jehovah’s Witness. AMA Vice President Dr Stephen Parnis said doctors could not force a patient to accept treatment.

Not in the script – chemists selling your data, Sunday Mail Adelaide, 12 April 2015

Some chemists are selling their patients’ prescription information to a global health information company, which sells it on to drug firms, trying to boost their sales. AMA Chair of General Practice Dr Brian Morton called it an amazing invasion of privacy for purely commercial reasons.

Coalition’s ‘no jab, no pay’ policy ties benefits to immunisation, Australian Financial Review, 13 April 2015

Australian parents will lose thousands of dollars’ worth of childcare and welfare benefits if they refuse to vaccinate their children. AMA President A/Professor Brian Owler said the AMA backed the plan and said vaccination remained one of the most effective public health measures that we have.

Hospitals ‘storm’ warning, Adelaide Advertiser, 16 April 2015

The number of public hospital beds across Australia has fallen by more than 200 and no State has met emergency department targets. AMA President A/Professor Brian Owler said hospital performance benchmarks are not being met and things will only get worse as funding declines. 

AMA hospital report card gives states fuel for fight, The Australian, 16 April 2015

Tony Abbott will face heightened pressure to reverse cuts of $80 billion to health and education, with a snapshot of public hospital performance handing the states fresh ammunition to press home their case. AMA President A/Professor Brian Owler will use the report to warn the Government that its extreme public hospital cuts are unjustified.

Church no longer exempt for jabs, Hobart Mercury, 20 April 2015

A religious exemption loophole, that allowed parents who opposed vaccinations to continue to receive childcare and family tax payments has been scrapped. AMA President A/Professor Brian Owler praised the move.

AMA warns against continued freeze on rebates, ABC News, 22 April 2015

AMA President A/Professor Brian Owler said at a time when the Government should be increasing its investment in general practice, the Medicare rebate freeze will eat away at the viability of individual practices.

Rape row over new anti-jab campaign, Adelaide Advertiser, 23 April 2015

A Facebook graphic on the Australian Vaccination Network site that compares vaccination to rape has been condemned by doctors, the Rape Crisis Centre, and politicians as abhorrent and insulting. AMA President A/Professor Brian Owler said the post undermines the organisation and shows lack of intelligence and common sense.

Doctors back review of Medicare rebates, West Australian, 23 April 2015

Doctors have backed a sweeping review of the Medicare Benefits Schedule, but warned the Federal Government not use it as an excuse to cut patient services. AMA President A/Professor Brian Owler agreed the MBS was outdated and said any savings from the review should be reinvested into the health system.

Aussie in sick new IS video, Sunday Herald Sun, 26 March 2015

The shocking new public face of Islamic State death cult is an Australian doctor. AMA President A/Professor Brian Owler said he was appalled that any medical professional would want to work for terrorists.

Transparency on dug company payments and trips a step closer, The Age, 28 April 2015

Patients will find out what payments and educational trips their doctors have received from drug companies. AMA Chair of General Practice Dr Brian Morton said it was insulting and naïve to suggest doctors would be unduly influenced by a free meal.

Terror doctor free to practise, Adelaide Advertiser, 28 April 2015

The Medical Board is refusing to deregister the former Adelaide doctor who left Australia to join the Islamic State terrorist group. AMA Vice President Dr Stephen Parnis said he expected the Medical Board to look closely at the case from legal and professional standards perspectives.

Scientists call for action on disease risks from climate change, Sydney Morning Herald, 30 April 2015

The Australian Academy of Science has released a report which shows a range of tropical diseases becoming more widespread in Australia due to climate change. AMA President A/Professor Brian Owler said the report should be a catalyst for the Abbott government to show leadership on reducing greenhouse gas emissions and mitigating their effects on health.

Radio

A/Professor Brian Owler, 774 ABC Melbourne, 7 April 2015

AMA President A/Professor Brian Owler talked about the decision to axe the proposed $5 Medicare co-payment in favour of an alternative Government plan to freeze the amount received by doctors in rebates.

Dr Stephen Parnis, 6PR Perth, 13 April 2015

AMA Vice President Dr Stephen Parnis discussed the use of the welfare system to boost immunisation rates. Dr Parnis said in the 1990s the Howard Government also linked immunisation to social security, which resulted in a big increase in vaccination rates.

A/Professor Brian Owler, Radio National, 16 April 2015

AMA President A/Professor Brian Owler discussed Federal funding for health. A/Professor Owler said the health system has never been adequately funded and doctors and nurses have done well to meet a rise in demand.

A/Professor Brian Owler, 2SM Radio, 16 April 2015

AMA President A/Professor Brian Owler talked about the use of paw paw for chronic back pain. A/Professor Owler said paw paw is a well-known treatment, but that people do not tend to use it as much nowadays.

A/Professor Brian Owler, 4BC Brisbane, 16 April 2015

AMA President A/Professor Brian Owler talked about the issue of health funding and the AMA Public Hospital Report Card. A/Professor Owler said the issue is capacity and resources, and that he is concerned about the future given reduced Commonwealth funding.

Dr Stephen Parnis, 2GB Sydney, 23 April 2015

AMA Vice President Dr Stephen Parnis talked about the recent Facebook post from the Australian Vaccination Skeptics Network, which compares forced vaccination to rape. Dr Parnis said the campaign shows how disgraceful and unhinged some anti-vaccination campaigners are.

A/Professor Brian Owler, 2UE Sydney, 28 April 2015

AMA President A/Professor Brian Owler talked about the Medical Board’s handling of the case of an Australian-registered doctor who has joined Islamic State. A/Professor Owler said he understands the Medical Board is working with security agencies to ensure that the public is safe, and to prevent any possibility of Dr Kamleh returning to Australia to continue practising medicine.

A/Professor Brian Owler, ABC NewsRadio, 30 April 2015

The Australian Academy of Science is warning of the impacts of global warming predicting food and water shortages, along with extreme weather events. AMA President A/Professor Brian Owler said climate change has been a political battleground and that Australia is not ready to cope with its impacts.

Television

A/Professor Brian Owler, Channel 9, 16 April 2015

AMA President A/Professor Brian Owler talked about the AMA’s Public Hospital Report Card. A/Professor Owler said many hospitals are not reaching targets in the emergency department treatment and elective surgery wait times.

Dr Stephen Parnis, Channel 9, 12 April 2015

AMA Vice President Dr Stephen Parnis talked about the Government’s announcement that childcare rebate payments will be cut for families who do not vaccinate their children. Dr Parnis said the children involved are innocent, and their futures need to be insured.

A/Professor Brian Owler, ABC News 24, 16 April 2015

AMA President A/Professor Brian Owler discussed the crisis in Australia’s public hospitals as Commonwealth funding is wound back. A/Professor Owler said the Commonwealth are not living up to their responsibilities to fund States and Territories properly to run hospitals. 

A/Professor Brian Owler, Channel 9, 22 April 2015

AMA President A/Professor Brian Owler discussed welcoming the plans for a major review of the Medicare Benefits Schedule. A/Professor Owler said the review is clinician-led and is not just about finding savings.

A/Professor Brian Owler, Sky News, 29 April 2015

AMA President A/Professor Brian Owler discussed the future of the public hospital system if Federal Government cuts come into effect. A/Professor Owler said state governments lack the capacity to increase revenue to pick up the slack.

A/Professor Brian Owler, ABC News 24, 30 April 2015

AMA President A/Professor Brian Owler called on the Federal Government to show leadership on climate change or risk the health of Australians. A/Professor Owler said there was overwhelming scientific consensus that the climate is changing and there will be consequences for health.

 

Your AMA Federal Council at work

What AMA Federal Councillors and other AMA members have been doing to advance your interests in the past month:

 

Name

Position on Council

Activity/Meeting

Date

A/Prof Brian Owler

AMA President

Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia

5/3/2015

Meeting with Royal Australasian College of Surgeons and Australian Plastic Surgery Association Presidents

4/3/2015

Dr Brian Morton

AMA Chair of General Practice

GP Roundtable

8/4/2015

UGPA

25/03/2015

GP Roundtable

17/3/2015

Dr Stephen Parnis

AMA Vice President

Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications

5/3/2015

Dr Andrew Miller

AMA Federal Council Representative for Dermatologists

PBS Authority medicines review reference group

13/4/2015

 

MSAC (Medical Services Advisory Committee) Review Working Group for Skin Services

20/2/2015

Dr Antonio Di Dio

AMA Member

Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications

5/3/2015

Dr Roderick McRae

AMA Federal Councillor – Salaried Doctors

Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications

5/3/2015

Dr Susan Neuhaus

AMA Federal Councillor – Surgeons

Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications

5/3/2015

Dr Robyn Langham

AMA Federal Councillor – Victoria nominee and Chair of AMA Medical Practice Committee

Australian Health Practitioner Regulation Agency’s (AHPRA) Prescribing Working Group (PWG)

5/3/2015

Dr David Rivett

AMA Federal Councillor

IHPA Small Rural Hospitals Working Group

5/2/2015

Dr Chris Moy

AMA Federal Councillor

PCEHR Safe Use Guides consultation (KPMG/ACSQHC)

11/3/2015

NeHTA (National E-Health Transition Authority) Clinical Usability Program (CUP) Steering Group

19/2/2015

Dr Richard Kidd

AMA Federal Councillor

PCEHR Safe Use Guides consultation (KPMG/ACSQHC)

10/3/2015

 

Gateway Advisory Group

9/2/2015

 

 

 

An enhanced recovery after surgery program for hip and knee arthroplasty

Osteoarthritis is the leading cause of pain and disability among the elderly and affects 15% of the population. Despite a range of treatments for osteoarthritis (OA), joint replacement remains the main treatment option for patients in whom the disease has progressed.1

In Victoria, more than 20 000 hip and knee joint replacements are now performed each year, reflecting orthopaedic practices globally. The prevalence of OA and the need for joint replacement are likely to increase because of a combination of increasing risk factors (age, obesity) and improved surgical and anaesthetic techniques that make surgery possible for more people.1

Across health services, there is wide variation in hospital length of stay for patients receiving hip and knee replacements. This is probably independent of casemix and more reflective of varying health service practices. Surgical injury, pain, stress-induced catabolism, impaired organ function and impaired cognitive function may contribute to complications, prolonged hospitalisation, postoperative fatigue, delayed convalescence and the need for rehabilitation. Optimisation of individual care components in perioperative care (the fast-track methodology) reduces the need for prolonged hospitalisation and convalescence, and reduces morbidity, with subsequent economic savings.2–6 Enhanced recovery after surgery (ERAS) programs are a care package of evidence-based interventions used in a multimodal, integrated clinical care pathway to achieve improved functional outcomes and rapid recovery.6 ERAS pathways have led to reduced hospital stays after hip or knee replacements — as short as 3 days in many centres.5–8

We aimed to assess the extent to which a predefined ERAS program for orthopaedic surgical patients could be achieved, and to evaluate improvements in quality of care and patient outcome across three public hospitals in Victoria.

Methods

We used a before-and-after study design consisting of three phases. Public health services involved in the study were the Alfred, Bendigo and Monash hospitals.

Phase 1: over the 6 months before implementation of the ERAS program, we recorded perioperative data for all eligible patients undergoing surgery (the existing-practice cohort).

Phase 2: training of staff managing orthopaedic surgical patients. For 1 month, the evidence-based background to ERAS was promulgated to all surgical, anaesthetic and nursing staff. This was done in various forms including lectures, workshops, meetings and written instructions.

Phase 3: change performance. We undertook a repeat audit following the implementation of the ERAS care package (the ERAS cohort).

Our study received ethics approval as an audit project with a waiver for specific patient consent (Alfred Human Research Ethics Committee, EC 92/12).

The pre-ERAS phase ran from March to September 2012. Training of staff took place over September 2012. The ERAS phase ran from October 2012 to May 2013.

Patient health status was quantified using the American Society of Anesthesiologists physical status classification, ranging from 1 (healthy patient) to 5 (moribund patient not expected to survive without the operation). Patient quality of recovery was assessed using the patient-centred, 15-item quality-of-recovery score,9 and the 12-item World Health Organization Disability Assessment Schedule 2.0 score.10 Indicators of patient satisfaction were assessed at 30 days after surgery using a 5-item Likert scale (0 = strongly agree, 5 = strongly disagree).

Actual hospital stay was timed from the beginning of surgery until discharge. We evaluated readiness for discharge on postoperative Day 3, defined by whether patients were eating and drinking, had no drain tubes or urinary catheters, were weight-bearing, and had well controlled pain scores (visual analogue scale with a range of 0 to 10) at rest and on movement of less than 3 and 5, respectively.

A successful ERAS implementation required at least 11 of 16 prespecified ERAS items (Box 1).

On completion of our study, there was a concern raised by the surgical team at the lead institution regarding an apparent increased incidence of acute kidney injury (AKI). In view of the widespread use of local anaesthetic infiltration with a solution that included ketorolac 30 mg, we chose to investigate this more formally at the lead institution. We retrospectively retrieved all perioperative creatinine data for the study cohorts. AKI was defined according to AKI Network11 and RIFLE (risk, injury, failure, loss, end-stage kidney disease)12 criteria. We did not include urine output or oliguria in the definitions of AKI, in part because we did not collect these data, but primarily because urine output is an unreliable indicator of renal function in the perioperative setting.

To account for the restrictive intravenous (IV) fluid regimen used in the ERAS cohort (which may have artificially elevated serum creatinine because of the avoidance of a dilutional effect from excessive IV fluids increasing body water), we calculated the adjusted creatinine concentration by first estimating the volume of distribution for creatinine as equal to total body water (assumed to be 60% of body weight, expressed in mL), and assuming that 50% of IV fluid was still accumulated as tissue oedema at the time of postoperative creatinine measurements:13

adjusted creatinine concentration = serum creatinine concentration × (1 + [0.5 × IV fluid balance/total body water])

Analysis of the data showed that there was no increased incidence of AKI in the ERAS group (Appendix 1).

The primary end point of the study was duration of hospital stay. Secondary end points were adherence to the ERAS bundle (defined as ≥ 11 items), and a number of patient outcome measures. A sample size calculation based on a change in hospital stay from a mean of 7 days (SD, 4 days) to 6 days (SD, 3 days), with an α value of 0.05 and a β value of 0.2, required at least 380 patients to be enrolled, but we included a larger sample in view of the planned subgroup analyses. Continuous data are reported as mean (SD) or median and interquartile range (IQR). Numerical data were first tested for normality using the Kolmogorov–Smirnov test and then compared using the Student t test or Wilcoxon rank–sum test, as appropriate. Rates were compared using χ2 or Fisher exact test, as appropriate. Hospital stay was expected to be skewed to the right because of a small proportion experiencing complications and a protracted hospital stay. Therefore, we log-transformed hospital stay data to enable valid comparison using the t test; in addition, we report median (IQR) length of stay and results of Wilcoxon rank–sum testing. Patients undergoing each type of surgery were also analysed as subgroups. A P value of less than 0.05 was considered statistically significant. Data were analysed with SPSS version 20.0 for Windows (SPSS Inc).

Results

We enrolled 709 patients into the project; 412 in the existing-practice cohort and 297 in the ERAS cohort (Box 2). We achieved 100% patient follow-up to hospital discharge and 90% follow-up at 6 weeks; there were 41 (10%) and 25 (8%) patients missing in each cohort, respectively. Comparison of data from the three hospitals showed that the patients were similar demographically as well as having similar rates of physical functioning and comorbidity. The existing-practice and ERAS cohorts, with the exception of some medications, were comparable (Box 2), which allowed unadjusted analyses between groups.

The ERAS program led to a significantly higher rate of successful implementation of this clinical pathway (2% v 81%; P < 0.001) (Box 3, Box 4, Box 5 and Appendix 2). The post-implementation cohort had a significantly increased number of ERAS interventions compared with the existing-practice group (median, 12 [IQR, 10–13] v 8 [IQR, 7–10]; P < 0.001).

Overall, there was a significant reduction in hospital stay (geometric mean, 5.3 [SD, 1.6] v 4.9 [SD, 1.6] days [P < 0.001]) (Box 4), with around half of the patients being discharged from hospital within 5 days of surgery (ERAS group, 60% v existing-practice group, 52%; P = 0.086). For those undergoing knee replacement surgery, the ERAS program was associated with a reduced hospital stay (geometric mean, 5.3 [SD, 1.6] v 4.5 [SD, 1.5] days [P = 0.001]; median, 5.0 [IQR, 4.0–6.7] v 4.1 [IQR, 3.0–6.0] days [P = 0.005]); and a greater proportion of patients were more likely to be discharged by Day 5 (64% v 52%; P = 0.019). There was no change in median hospital stay for hip replacement patients in the ERAS group compared with the existing-practice group (median, 5.0 [IQR, 3.5–7.0] v 5.0 [IQR, 4.0–6.9] days; P = 0.99). Overall, the 75th centile for length of stay decreased from 6.8 to 6.0 days.

We found high rates of compliance with nearly all ERAS items (Box 3). There was increased use of spinal anaesthesia. The use of femoral nerve block (with or without a catheter) was substituted by favouring surgeon-delivered local anaesthetic infiltration in 75% of cases; this change in practice varied across the three hospitals (98%, 37% and 98%). There were improved dynamic pain scores and quality of recovery (Box 4). There were improvements in other recovery parameters (early feeding, ambulation and removal of tubes). Patients undergoing knee replacement had improved flexion on postoperative Days 1 and 2.

The proportion of patients ready for discharge on Day 3 after surgery was significantly higher in the ERAS group compared with the existing-practice group: 59% v 41%, respectively; relative risk, 1.35 (95% CI, 1.18–1.53); P < 0.001 (Box 6 and Appendix 1).

The 6-week complication rates were similar and there was no increase in the rate of hospital readmission. Pain levels were similar and there was a higher level of patient satisfaction at 6 weeks after surgery (Box 5).

The incidence of AKI was comparable between groups (Appendix 1). The final plasma creatinine values were slightly higher in the ERAS group, but this could be accounted for by higher baseline (preoperative) values; ERAS patients had a mean change in creatinine from 78 mmol/L (SD, 24 mmol/L) preoperatively, to a final reading of 79 mmol/L (SD, 24 mmol/L) postoperatively. There were no cases of renal failure.

Discussion

Our study results indicate that implementing an ERAS program may be beneficial for other Victorian public hospitals. The ERAS program had a small but significant effect on hospital stay, particularly for knee replacement patients. A pertinent finding from our study was that a higher proportion of patients managed through the ERAS care pathway compared with the existing-practice group (59% v 41%, respectively) were deemed ready for discharge on postoperative Day 3.

The limited effect on actual hospital stay in this project is likely to be due to one key factor: despite an effectively implemented ERAS program, there were entrenched hospital practices that prevented earlier hospital discharge even though patients were deemed ready for discharge; that is, discharge planning practice was mostly unchanged. This is due to established ward practices, including a repetitive requirement for many joint replacement patients to undergo their initial rehabilitation program as an inpatient (delaying their discharge). Patients referred for rehabilitation often wait for some time (hours or days) before being reviewed by rehabilitation services. Further, if surgery occurred on a Thursday or Friday, patients had minimal access to physiotherapy over the weekend. These aspects offer opportunities for improvement. The challenge is clear: to convert improvement in care (and outcome) into shorter hospital stay.

Our primary end point was duration of hospital stay. As we have done previously,14 we used a log-transformation and compared geometric means to account for skewness of our data (a small proportion of patients staying in hospital for very long times distorts central tendency — a well known phenomenon for many types of surgery). A secondary non-parametric comparison of median stays was not statistically significant. Therefore, we reported the 75th centiles to illustrate the observed improvement in hospital stay for the majority of patients.

Administrative and traditional patterns of clinical practice limit opportunities for change and are common causes of delayed discharge from hospital.14–16 Perhaps specific fast-track arthroplasty units that have evidence-based and protocolised rapid recovery pathways can optimise cost-efficient quality outcomes after hip and knee replacement surgery.15 This could reduce hospital costs, improve patient satisfaction with care and potentially reduce perioperative morbidity.

We demonstrated that an ERAS program for orthopaedic joint replacement can be achieved. We markedly improved most indicators of processes related to an ERAS program. These included preadmission patient education, reduced fasting times, clear oral fluids, written instructions (including expected day of discharge), less blood loss, better pain relief, earlier ambulation and better overall quality of recovery. Similar success has been reported in other countries.8,17,18 Medical teams can be trained to deliver an ERAS program and this clearly improves the quality of care.

We clearly demonstrated that we could successfully implement a predefined ERAS program for orthopaedic surgical patients in public hospitals, and that doctors and nurses could follow such a regimen to improve outcome parameters. There was high uptake of nearly all ERAS items. This led to clinically important improvements in care, a small reduction in hospital stay for knee replacement patients, and an overall improvement in some aspects of patient satisfaction. There was evidence of improved quality of recovery. There was no effect on most complications and no adverse effect on hospital readmission rates.

Our 6-week complication rates are lower than those reported in most studies, the largest of which included 4500 consecutive unselected hip and knee replacements.5 In that study, the first 3000 patients represented existing or traditional practice and a further 1500 patients underwent an ERAS protocol similar to that used in our study. This group reported a decrease in length of stay from 6 days to 3 days (P < 0.001), as well as a reduction in 30-day mortality (from 0.5% to 0.1%; P = 0.02) and 90-day mortality (from 0.8% to 0.2%; P = 0.01). Blood transfusion was reduced from 23% to 9.8% (P < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (from 0.8% to 0.5%; P = 0.2) and stroke (from 0.5% to 0.2%; P = 0.2). There was no measurable effect on deep vein thrombosis (0.8% v 0.6%; P = 0.5) or pulmonary embolism (1.2% v 1.1%; P = 0.9).

There were some limitations of our study. It was not a randomised trial and there may have been some imbalance between the groups that we did not account for. The study was unblinded and we compared numerous secondary end points. Although there are likely to be cost benefits of an ERAS program, we did not undertake any health costing analyses.

We found a high level of general acceptance and uptake of the ERAS program and, on the whole, it had a positive effect on patients and staff. We can recommend this orthopaedic ERAS pathway.

Anchor

1 Sixteen predefined enhanced recovery after surgery items for hip or knee arthroplasty

  • Nurse coordinator counselling in the orthopaedic or preadmission clinic
  • Preadmission review by a physiotherapist and/or dietitian
  • Minimal fasting preoperatively, defined as clear oral fluids up to 2 hours before surgery
  • Preoperative oral carbohydrate loading
  • No sedative premedication (benzodiazepines, opioids or neuroleptics)
  • Pre-emptive analgesia with paracetamol and gabapentinoids according to protocols
  • Spinal anaesthesia (not epidural)
  • Local anaesthesia technique (surgeon-delivered local infiltration of analgesia or anaesthetic femoral nerve block)
  • Minimal (≤ 10 mg) intravenous morphine intraoperatively
  • Intraoperative avoidance of excessive intravenous fluids (knee, > 1 L; hip, > 2 L; both: subtracting blood loss)
  • Active intraoperative warming (forced air warming and/or warmed intravenous fluids)
  • Antiemetic prophylaxis
  • Multimodal oral analgesia for ≥ 3 days postoperatively, to include a non-steroidal anti-inflammatory drug or cyclooxygenase-2 inhibitor
  • Early postoperative (recovery room) oral carbohydrate supplementation
  • Mobilisation within 24 hours
  • Early hospital discharge (≤ 5 days)

2 Patient demographic and perioperative characteristics*

Variable

Existing practice (n = 412)

ERAS (n = 297)

P

Sex, male

164 (40%)

113 (38%)

0.64

Mean age, years (SD)

68 (11)

67 (10)

0.22

Mean weight, kg (SD)

84 (19)

87 (20)

0.092

Medical history

      

Current smoker

46 (11%)

30 (10%)

0.65

Hypertension

284 (69%)

194 (65%)

0.31

Coronary artery disease

70 (17%)

41 (14%)

0.25

Stroke

20 (5%)

10 (3%)

0.33

Heart failure

19 (5%)

15 (5%)

0.86

Peripheral vascular disease

13 (3%)

8 (3%)

0.72

Diabetes

81 (20%)

73 (25%)

0.12

COPD

88 (21%)

67 (23%)

0.70

Preoperative anaemia

36 (9%)

22 (7%)

0.52

Usual medications

      

Opioid

106 (26%)

58 (20%)

0.053

Aspirin within 5 days

58 (14%)

54 (18%)

0.14

Clopidogrel within 7 days

2 (< 1%)

0

0.23

Warfarin within 7 days

22 (5%)

6 (2%)

0.025

NSAID/COX-2 inhibitor

109 (26%)

109 (37%)

0.004

ACE inhibitor/ARB

235 (57%)

168 (57%)

0.90

Beta blocker

71 (17%)

51 (17%)

0.98

Statin

141 (34%)

89 (30%)

0.37

Calcium channel blocker

98 (24%)

73 (25%)

0.81

Diuretic

120 (29%)

79 (27%)

0.45

Oral hypoglycaemic

57 (14%)

60 (20%)

0.024

Insulin

9 (2%)

11 (4%)

0.25

LMWH

20 (5%)

8 (3%)

0.15

ASA physical status

    

0.57†

1

 10 (2%) 10 (3%)  

2

 223 (54%) 161 (54%)  

3

 172 (42%) 122 (41%)  

4

7 (2%)

3 (1%)

  

Disease

    0.22

Osteoarthritis

 367 (89%) 275 (93%)  

Rheumatoid arthritis

 4 (1%)    

Avascular necrosis

 14 (3%) 7 (2%)  

Other

 27 (7%) 15 (5%)  

Previous PONV or motion sickness

 124 (30%) 81 (27%) 0.41

ACE = angiotensin-converting enzyme. ARB = angiotensin-receptor blocker. ASA = American Society of Anesthesiologists. COPD = chronic obstructive pulmonary disease. COX = cyclooxygenase. ERAS = enhanced recovery after surgery, LMWH = low molecular weight heparin. NSAID = non-steroidal anti-inflammatory drug. PONV = postoperative nausea and vomiting. * Data are no. (%) of patients unless otherwise specified. † P value derived from χ2 test for trend.

3 Perioperative and surgical care*

Variable

Existing practice (n = 412)

ERAS (n = 297)

P

Preadmission clinic, seen by:

      

Nurse†

406 (99%)

297 (100%)

0.037

Anaesthetist

405 (98%)

297 (100%)

0.024

Surgeon

406 (99%)

297 (100%)

0.037

Physiotherapist†

331 (80%)

224 (75%)

0.12

Occupational therapist

324 (79%)

249 (84%)

0.077

Dietitian†

0

61 (21%)

< 0.001

Day of surgery

      

Admission on day of surgery

404 (98%)

294 (99%)

0.32

Shower with antibiotic soap

399 (97%)

238 (80%)

< 0.001

Preoperative skin wipes

4 (1%)

91 (31%)

< 0.001

Oral (clear) fluids given†

2 (< 1%)

180 (61%)

< 0.001

Oral carbohydrate drink†

0

248 (84%)

< 0.001

Gabapentin premedication†

21 (5%)

172 (58%)

< 0.001

Type of surgery

      

Hip

214 (52%)

129 (43%)

0.025

Knee

198 (48%)

168 (57%)

0.025

Revision

26 (6%)

13 (4%)

0.26

Tubes

      

Urinary catheter

200 (49%)

107 (36%)

0.001

Drain tube(s)

105 (25%)

59 (20%)

0.080

Type of anaesthesia

      

General (± regional)

266 (65%)

164 (55%)

0.014

Spinal†

236 (57%)

205 (69%)

0.001

Epidural or CSE

16 (4%)

3 (1%)

0.019

Postoperative regional analgesia

      

Nerve block used

135 (33%)

44 (15%)

< 0.001

LA infiltration†

214 (52%)

222 (75%)

< 0.001

PONV prophylaxis†

233 (57%)

202 (68%)

0.002

Mean total IV fluids, mL (SD)†

1756 (767)

1446 (687)

< 0.001

Active (forced air) warming†

392 (95%)

285 (96%)

0.34

Mean lowest temperature, °C (SD)

35.7 (0.5)

36.2 (0.4)

0.039

Mean duration of surgery, hours (SD)

2.0 (0.9)

1.9 (0.6)

0.33

CSE = combined spinal and epidural. ERAS = enhanced recovery after surgery. IV = intravenous. LA = local anaesthesia. PONV = postoperative nausea and vomiting. * Data are no. (%) of patients unless otherwise specified. † Key ERAS implementation points.

4 Recovery profile and hospital stay

Variable

Existing practice (n = 412)

ERAS (n = 297)

P

Recovery room

      

Median pain score (IQR), at rest*

0 (0–5)

0 (0–4)

0.047

Median pain score (IQR), on movement*

0 (0–7)

0 (0–4)

< 0.001

Admission temperature, °C (SD)

36.1 (0.5)

36.0 (0.6)

0.006

Postoperative, at 24 hours

      

Median pain score (IQR), at rest*

5 (3–7)

4 (2–5)

< 0.001

Median pain score (IQR), on movement*

6 (4–8)

5 (3–7)

< 0.001

Mean quality of recovery score (SD) (range, 0–150)

103 (19)

106 (20)

0.056

Total knee replacement

      

Mean knee flexion (SD), degrees

 51 (19) 57 (24) 0.026

Median quadriceps strength (IQR), Nm

 3 (2–3)

2 (2–3)

0.11

Postoperative, at 48 hours

      

Median pain score (IQR), at rest*

4 (2–6)

3 (1–5)

< 0.001

Median pain score (IQR), on movement*

6 (4–8)

5 (2–7)

0.001

Total knee replacement

      

Mean knee flexion (SD), degrees

72 (19)

78 (14)

0.009

Median quadriceps strength (IQR), Nm

3 (2–3)

3 (2–3)

0.90

Recovery parameters, median hours (IQR)

      

Weight bearing

1.1 (1.0–2.0)

1.0 (0.9–2.0)

0.001

Oral fluid intake

3.2 (2.0–5.0)

2.7 (1.7–4.1)

0.016

Oral food intake

7.0 (4.3–15)

6.3 (3.2–7.9)

0.004

Removal of drain tubes

27 (24–42)

25 (23–27)

0.002

Removal of urinary catheter

48 (42–76)

33 (17–60)

< 0.001

Blood transfusion in hospital, no. of patients (%)

58 (14%)

31 (10%)

0.24

Return to theatre, no. of patients (%)

14 (3%)

10 (3%)

0.76

Length of stay, days

      

Geometric mean (SD)

5.3 (1.6)

4.9 (1.6)

< 0.001

Median (IQR)

5.0 (4.0–6.8)

5.0 (3.8–6.2)

0.10

ERAS = enhanced recovery after surgery. IQR = interquartile range. * Visual analogue scale: 0 = none, 10 = severe.

5 Recovery profile at 6 weeks after surgery*

Variable

Existing practice (n = 412)

ERAS (n = 297)

P

Wound infection

21 (5%)

13 (4%)

0.99

Prosthesis infection

5 (1%)

2 (< 1%)

0.60

Prosthetic joint dislocation

2 (< 1%)

3 (1%)

0.31

Periprosthetic fracture

0

0

> 0.99

Thromboembolism

13 (3%)

10 (3%)

0.59

Urinary tract infection

8 (2%)

2 (1%)

0.22

Death

2 (< 1%)

1 (< 1%)

0.85

Worst pain rating in past 24 hours†

2 (0–4)

2 (0–3)

0.01

Extent of disability in past 24 hours†

2 (0–3)

1 (0–2)

0.37

Patient satisfaction‡

      

Was surgery worthwhile?

1 (1–2)

1 (1–1)

< 0.001

Did surgery improve your daily life?

1 (1–2)

1 (1–2)

0.015

Do you feel better?

1 (1–2)

1 (1–2)

< 0.001

Do you have trouble sleeping?

3 (2–4)

3 (2–4)

0.67

Hospital readmission

25 (6%)

15 (5%)

0.87

ERAS = enhanced recovery after surgery. * Data are no. (%) of patients or median score (IQR). † Visual analogue scale: 0 = none, 10 = severe. ‡ 5-point Likert scale: 0 = strongly agree, 5 = strongly disagree.

6 Proportion of patients ready for discharge on Day 3 after surgery*

ERAS = enhanced recovery after surgery. * P < 0.001.

No early relief for cash-strapped hospitals

Hopes of short-term funding relief for the nation’s cash-strapped public hospitals have been dashed following a decision of the nation’s political leaders to defer discussions on the issue to a special retreat to be held in July.

In a sign that there will be little new spending on public hospitals in next month’s federal Budget, Prime Minister Tony Abbott has convinced his State and Territory counterparts to delay talks on health financing for consideration as part of proposals to reform the Federation.

AMA President Associate Professor Brian Owler said that, although doctors would have preferred the meeting to have reached an agreement on hospital funding, the fact that it would be on the agendas of the COAG leader’s retreat was welcome.

Mr Abbott said the country needed to take a “very holistic look” at the way it funded public hospitals to ensure “we get the best possible value for our dollar, because we’re under pressure”.

“Sure, the states and territories are under pressure for their hospital funding, but we’re under pressure for our tax take,” the Prime Minister said. “No-one is volunteering to pay more tax. So, we need to handle this in a way which acknowledges the need for ever-better health services, but which also appreciates that resources are not unlimited, and that’s what we want to be able to discuss in an honest and candid and collegial way as part of the leaders retreat later on in July.”

Treasury figures show the Federal Government’s decision to walk away from National Health Reform Agreement funding guarantees and cut the indexation rate of future contributions will rip $57 billion out of the public hospital system in the next 10 years.

The massive funding cuts are due to hit a system already showing signs of strain.

The AMA’s Public Hospital Report Card, released a day before Mr Abbott met with the nation’s premiers and chief ministers, showed that elective surgery waiting times remain stubbornly high (for the fourth year in a row the national median waiting time in 2013-14 was 36 days), admission delays remain unsatisfactory and the proportion of beds per population is shrinking.

A/Professor Owler warned the looming funding cuts would create “a perfect storm” for public hospitals already struggling to cope, and would cause patient waiting times to blow out.

“Public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care,” he said. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

The issue threatened to dominate the Council of Australian Governments meeting on 17 April after NSW Premier Mike Baird led a chorus of complaints from State and Territory leaders about the Commonwealth’s funding cutbacks.

But, following the meeting, Mr Baird said the fact that it would now be considered in the context of broader federal-state relations was “a tremendous step”.

“This is not just an individual state issue, it’s not a Commonwealth government issue – we have to do it together,” Mr Baird said. “It is a huge challenge. It is the number one challenge to our finances – full stop. Commonwealth and state.”

Setting the tone for discussions, Mr Abbott made it clear that, while acknowledging the increased financial pressure on the states, the Commonwealth would not be putting more money on the table.

“I accept that, with public hospitals in particular, there are a lot of cost pressures, I absolutely accept that,” the Prime Minister said. “I’m a former Health Minister, I know all about the health rate of inflation, [that it] tends to exceed the general rate of inflation because all the time we’re coming up new and better treatments which are very expensive.”

In the absence of more money, focus is turning to identifying further savings and efficiencies in the way the health system is managed and care is provided.

Mr Abbott said that although this would include examining funding arrangements, more importantly it must also involve overhauling “the structures” to achieve greater efficiencies.

Mr Baird said that “the only way we can deal with it is come together, and what we need to do…is look at the roles and responsibility; can we do it better, can we do it smarter, take away duplication, and can we make sure that we have got the funding to continue to deliver the health care services we do and, importantly, it has to be patient focussed.”

Adrian Rollins

 

Patients face longer delays as ‘perfect storm’ set to hit stressed public hospitals

Patients face increasingly lengthy waits for hospital care as the Federal Government squeezes funding despite rising demand, creating a “perfect storm” for the nation’s hospitals, AMA President Associate Professor Brian Owler has warned.

As Prime Minister Tony Abbott prepares to meet with State and Territory leaders tomorrow, the AMA’s annual Public Hospital Report Card, released today, shows that, despite the best efforts of doctors and other health professionals, who are working increasingly efficiently and effectively, hospitals are struggling to meet the needs of an expanding and ageing population.

In a clear sign of a system under stress, the national median waiting time for elective surgery has remained stuck at historically high levels.

For the fourth year in a row, patients waited an average of 36 days for elective surgery in 2013-14, almost 10 days longer than they were a decade earlier.

Meanwhile, less than 80 per cent of category 2 patients were admitted within the clinically recommended time of 90 days last financial year, well short of the national target.

Evidence of the strain on public hospitals is set to add to the pressure on Mr Abbott when he meets the nation’s premiers and chief ministers at the Council of Australian Governments in Canberra tomorrow.

Treasury has admitted that Commonwealth funding cuts unveiled in last May’s Budget and December’s Budget update will strip $57 billion from public hospitals between 2017-18 and 2024-25.

The cuts have outraged the premiers who, led by NSW Premier Mike Baird, intend to press Mr Abbott at the COAG meeting to restore the funds.

A/Professor Owler said the States and Territories were facing “a huge black hole in public hospital funding after a succession of Commonwealth cuts”.

“The hospital funding blame game is back, and bigger than ever. Public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care,” he said. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

A/Professor Olwer warned that “a perfect storm” was building ahead of new, lower indexation arrangements for Commonwealth public hospital funding due to come into effect from 2017-18 that will reduce funding from its already inadequate levels, further hampering performance and undermining patient care.

“State and Territory Governments, many of which are already under enormous economic pressures, will be left with much greater responsibility for funding public hospital services,” he warned. “Performance against benchmarks will worsen and patients will suffer. Waiting lists will blow out.”

The AMA said the situation in the nation’s public hospitals was already even worse than the data in the Report Card suggested.

It said official figures disguised the true length of delays that elective surgery patients faced because they only started to count waiting time from when the patient saw their specialist, rather than from the time of referral by their GP.

“This means that the publicly available elective surgery waiting list data actually understate the real time people wait for surgery,” the Report said. “Some people wait longer for assessment by a specialist than they do for surgery.”

Much of this is due to an inadequate number of beds and the staff to serve them.

The AMA’s analysis has found that hospitals have proportionately far fewer beds than they did 20 years ago, contributing to lengthy waits in emergency departments and for elective surgery.

The number of beds per 1000 people fell to just 2.57 per cent in 2012-13, down from 2.62 the previous year, and shows no sign of improving.

Among those most likely to need hospital care, the picture is just as bleak. The number of beds for every 1000 Australians aged 65 years and older has reached a record low of 17.5, a massive 56 per cent decline since the early 1990s.

“Public hospital capacity is not keeping pace with population growth, and is not increasing to meet the growing demand for services,” the report said.

A/Professor Brian Owler said the results showed that, even before the latest massive Federal Government funding cuts bite, public hospital performance was already being hit by inadequate resources.

In last year’s Budget, the Government announced measures that will rip $20 billion out of hospital funding in coming years, including the renunciation of spending guarantees and cut in funding indexation to the inflation rate plus population growth. These cuts were compounded late last year by a further $941 million reduction in spending over the next four years.

A/Professor Owler warned the funding cutbacks would entrench sub-par hospital performance.

“If it proceeds with its savings measures, the Commonwealth will lock in hospital funding and capacity at the inadequate levels demonstrated by current performance,” the AMA President said. “Without sufficient funding to increase capacity, public hospitals will never meet the targets set by governments, and patients will wait longer for treatment.”

The Government has argued budget cuts are necessary because health spending is growing unsustainably.

But A/Professor Owler said total health expenditure actual shrunk in 2012-13, and Commonwealth support was now “well short of [what is needed] to position public hospitals to meet increasing demand”.

The AMA Public Hospital Report Card 2015 can be viewed at the AMA website: ama.com.au

Adrian Rollins

 

 

 

 

Patients left stranded by health cover gaps

Patients are being forced into last-minute cancellations of vital surgery to repair eyesight, fix dodgy knees and hips and reconstruct hands, faces and chests ravaged by cancer because of unexpected gaps in their private health cover.

The AMA has called for private health insurance policies that exclude basic and common procedures to be banned, after a survey of AMA members found insurance companies are increasingly marketing policies with exclusions and caveats that patients do not fully understand, and which are forcing them to forego common procedures like cataract surgery, hip and knee joint operations and reconstructive breast, face and hand surgery.

In a submission to the Australian Competition and Consumer Commission on the private health insurance industry, the AMA said health funds were engaging in sharp practices that left consumers confused and unaware of major gaps and shortfalls in their cover.

“There is a significant disconnect between most consumers’ understanding of the services and rebates they are entitled to under their private health insurance policy and the reality of what their product provides,” the submission said.

It complained that insurers presented their products in a poor and confusing manner, and often they were explained incorrectly by frontline staff.

“The combined effect means that consumers have limited ability to ‘shop around’ and compare products, and to fully understand the products they have purchased,” the AMA said. “It is usually only at the time when people need to have medical treatment in a hospital that they first comprehend that their insurance policy is deficient.”

The number of policies being sold with exclusions and minimum benefits has accelerated as premiums have increased. A decade ago, just a third of policies had restrictions, exclusions or higher excess, but they account for around a half of all policies held now.

The Australian cited Private Healthcare Australia figures showing more than 985,000 policies were downgraded between February 2012 and December 2014, and the number is expected to surge higher following the latest average 6.2 per cent premium increase that came into effect on 1 April.

In its submission, the AMA said many practitioners were concerned that insurers were deliberately allowing people to take out health policies unlikely to suit their health needs, such as selling cover that excludes psychiatric care to patients with a chronic psychiatric condition.

In addition, firms are marketing changes to policies without fully explaining the consequences for consumers.

One doctor surveyed by the AMA reported that, “I’ve had patients who were told their premiums would not rise this year, but did not understand this had only happened because they had been shifted to a policy with exclusions. The detail was in the fine print”.

Insurers faced particular condemnation for marketing ‘public hospital only’ policies, which the AMA said were of no value to consumers.

One doctor observed that, “consumers are being sold a non-existent service because they wait the same amount of time for admission as public patients, and they are usually unable to choose their doctor. In some states or regional areas it’s completely useless because surgeons just can’t offer that service”.

In its submission, the AMA called for such policies to be withdrawn from the market.

The AMA reserved special condemnation for the pre-approval processes used by private health funds to try to dodge their obligations.

Under the Private Health Insurance Act 2007, private funds are required to pay benefits for hospital treatment for which a Medicare rebate is payable.

But AMA reported that some insurers were adopting a virtually default position of refusing to pay a claim, forcing patients to complain and challenge the decision.

“The two largest private health insurers are circumventing their obligations under the PHI Act by rejecting the payment of private health insurance benefits prior to procedures being performed,” the submission said. “In a situation where the…insurer refuses to pay, it is only the patient who has standing to pursue payment…through the courts. The reality is that few patients will do so.”

The AMA has called for policies that exclude common procedures, or provide cover only for treatment in public hospitals, to be banned.

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.  

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.  

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.