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Preference: Surgery

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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.

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.

Reduced breast milk feeding subsequent to cosmetic breast augmentation surgery

Breastfeeding is beneficial for infants and their mothers. It protects against diarrhoea, respiratory tract and other infant infections, atopic dermatitis, asthma, obesity, diabetes and cancer.1,2 Although exclusive breastfeeding achieves optimal infant growth and development, the World Health Organization recognises that providing some breast milk to the infant is better than none.3 For mothers, breastfeeding has a contraceptive effect, and reduces the risk of type 2 diabetes, breast cancer and ovarian cancer.1

Cosmetic breast augmentation is the most common plastic surgical procedure, and its use is rising dramatically. In Australia, this surgery increased by 150% between 2001 and 2011.4 In the United States, the estimated increase for this period was 45%, although this followed a 550% increase from 1992 to 2000.5 In the United Kingdom, rates increased by 200% from 2005 to 2013.6 In this article, cosmetic breast augmentation (or breast implants) refers to procedures that change the size, shape and texture of healthy breasts. This is distinct from reconstructive breast augmentation, such as following mastectomy.

Although most cosmetic breast surgery occurs among women of reproductive age, there has been little research into pregnancy outcomes, including breastfeeding. A systematic review of breastfeeding outcomes associated with cosmetic breast augmentation surgery identified only three small, observational studies.7 One study reported reduced rates of any breastfeeding among women with breast augmentation, while meta-analysis of all three studies suggested a reduced likelihood of exclusive breastfeeding (pooled rate ratio, 0.60; 95% CI, 0.40–0.90).7 The authors recommended that studies using larger cohorts and more representative study populations be used to explore the observed association.

To test the null hypothesis that augmentation has no effect on breast milk feeding, we conducted a population-based study to determine the effect of cosmetic breast augmentation: (i) on any breast milk feeding in a subsequent pregnancy; and (ii) on exclusive breast milk feeding among women who breast milk fed.

Methods

The study population was derived from the 391 979 women who gave birth in New South Wales from 1 January 2006 to 31 December 2011 (Box 1). As our intention was to examine the effect of cosmetic breast augmentation, women with breast cancer, mastectomy, breast reconstruction or other breast surgery before giving birth were excluded (n = 3831; Box 1 and Appendix 1). The remaining 388 148 women had 506 942 births. The first birth in the study period or the first birth after breast augmentation surgery was used in the primary analysis.

Data for the study were obtained from two linked population health datasets: the NSW Perinatal Data Collection (PDC; referred to as birth records) and the NSW Admitted Patient Data Collection (APDC; referred to as hospital records). The PDC is a statutory surveillance system of all births in NSW of at least 20 weeks’ gestation or at least 400 g birthweight. Information on maternal characteristics, pregnancy, labour, delivery, and infant outcomes are recorded by the attending midwife or doctor. The APDC is a census of all NSW inpatient hospital discharges from both public and private hospitals, and day procedure units, and includes demographic and episode-related data. Diagnoses and procedures are coded for each admission from the medical records according to the International Classification of Diseases, 10th revision, Australian modification (ICD-10-AM) and the Australian Classification of Health Interventions.8

Hospital records for individual women were linked cross-sectionally to birth records from 2006 to 2011 and longitudinally (from July 2000 to December 2011). Thus, the minimum lookback period for prior breast surgery ranged from 5.5 to 11.5 years. Record linkage was undertaken by the NSW Centre for Health Record Linkage (CHeReL). For this study, the CHeReL reported the quality of the record linkage9 as 3/1000 false-positive links. We were provided with anonymised data. Ethics approval for the study was obtained from the NSW Population and Health Services Research Ethics Committee.

Breastfeeding information at discharge has been collected in birth records since 2006. One or more of the following three options can be reported in tick-boxes: “breastfeeding”, “expressed breast milk” or “infant formula”.

The primary outcome was any breast milk feeding (any breast milk, with or without infant formula) at discharge from birth care. Consistent with other studies,7 the secondary outcome was exclusive breast milk feeding (only breast milk, either directly from the breast and/or as expressed breast milk) among those with any breast milk feeding.

The exposure of interest was cosmetic breast augmentation, which has a specific surgical procedure code (45528-00) in the Australian Classification of Health Interventions.4,8 This code is distinct from unilateral breast augmentation and breast augmentation following mastectomy. Hospital records from 2000 onwards were available for identification and date of surgery.

Other factors potentially predictive of breast milk feeding at discharge from maternity care that were available for analysis included: maternal age, country of birth, socioeconomic status according to the Australian Bureau of Statistics Index of Relative Socio-economic Disadvantage,10 marital status, urban or rural residence, private care, parity, multifetal pregnancy, antenatal care before 20 weeks’ gestation, smoking during pregnancy, morbid obesity, hypertensive disorders of pregnancy, diabetes (pregestational or gestational), labour analgesia, labour induction or augmentation, mode of birth, severe maternal morbidity,11 maternal postnatal length of stay, gestation, small for gestational age (< 10th birthweight for gestational age percentile), major congenital anomalies (eg, cleft lip or palate, spina bifida, tracheoesophageal fistula), neonatal intensive care unit admission, and perinatal mortality. These factors are known to be reliably reported.12

Statistical analysis

Descriptive statistics were used to summarise the distributions of maternal and pregnancy characteristics among all women with and without breast augmentation. Poisson regression modelling with robust standard errors13 was employed to determine the association of breast augmentation with (i) any breast milk feeding (compared with none) and (ii) exclusive breast milk feeding (compared with non-exclusive) among the “any breast milk feeding” group.

To avoid confounding by factors likely to be associated with reduced breastfeeding,14,15 regression analyses were limited to women who had a singleton infant with no major congenital anomalies and born at term (≥ 37 weeks). Crude and adjusted relative risks (RRs) with 95% confidence intervals were estimated for characteristics likely to be associated with breastfeeding.

Finally, among women with at least two births in the study period, we examined the primary and secondary breastfeeding outcomes across births in the following groups: no breast augmentation, breast augmentation between births, and breast augmentation before both births. The before-and-after effect of breast augmentation among women who had breast augmentation surgery between births was assessed using the McNemar test of paired data, with continuity correction.

Results

Of the 388 148 women who were eligible for the study, 902 had documentation of cosmetic breast augmentation surgery (Box 1). Breastfeeding information at discharge was missing in 9759 records (2.51%). Among the remaining 378 389 women, 892 (0.24%) had breast augmentation before a birth. The median age at the time of breast augmentation surgery was 28 years (range, 18–43 years), and the median interval between surgery and birth was 3.1 years (range, 1.0–10.1 years).

Maternal, pregnancy and birth characteristics for all women with and without breast augmentation are presented in Box 2. At discharge, 705 women (79.0%) with breast augmentation provided any breast milk to their infants, compared with 88.5% of women without breast augmentation.

Breast milk feeding outcomes were then assessed among 341 953 singleton infants with no major congenital anomalies born at term. Compared with women without, women with breast augmentation had reduced likelihood (adjusted RR, 0.90; 95% CI, 0.87–0.93) of feeding their infant with any breast milk at the time of discharge from birth care. Factors controlled for that were positively associated with breast milk feeding included: older maternal age, non-Australian-born, high socioeconomic status, nulliparity, non-smoker, no obstetric interventions, and longer hospitalisation after birth (Appendix 2). Women with breast augmentation in the 2 years preceding birth had similar rates of any breast milk feeding to women with a longer period since breast surgery (77% v 81%; P = 0.17).

For women whose infants received any breast milk, there was no association between breast augmentation and exclusive breast milk feeding. Among these, 593 women (94.0%) with breast augmentation exclusively breast milk fed. The adjusted RR for exclusive breast milk feeding among women with breast augmentation, compared to those without, was 0.99 (95% CI, 0.97–1.01).

Among the 106 835 women with two births during the study period, 106 593 had no record of breast augmentation, 167 had breast augmentation before both births, and 75 had breast augmentation between the two births. The rates of any breast milk feeding and exclusive breast milk feeding at the first and second births were compared for these three groups of women (Box 3). The rate of any breast milk feeding was the same for both births among women with no augmentation (87%). Among women with breast augmentation between the births, the rate declined from 87% in the first birth to 72% in the second birth (P = 0.02). There was no evidence of significant change among women with augmentation before both births (77.2% v 73.7%; P = 0.29; Box 3, A). However, among women who provided any breast milk, the rate of exclusive breast milk feeding was similar in first and second births for women with and without breast augmentation (Box 3, B).

Discussion

This is the first study to document the population prevalence of cosmetic breast augmentation in a maternity population, and the largest to compare breast milk feeding outcomes for women with and without cosmetic breast augmentation. We found that women with breast augmentation are less likely to provide their infants with any breast milk at the time of discharge. However, among women who provide breast milk, women with breast augmentation are no more or less likely to exclusively breast milk feed their infants. Both the main population analysis and the subgroup analysis of women with breast augmentation between births showed lower rates of any breast milk feeding following augmentation surgery. This consistency of findings strengthens the case that there is an effect, although possible mechanisms are unclear.

Uptake of breast augmentation surgery is increasing, with 8000 Australian, 10 000 British and 307 000 American women undergoing the procedure in 2011.4–6 We found that 79% of these women can be expected to breast milk feed at discharge, compared with 89% of women without surgery. As maternity care affects breastfeeding success,2 these findings underscore the importance of identifying, supporting and encouraging all women who are vulnerable to a lower likelihood of breastfeeding.

Underlying breast hypoplasia and insufficient lactogenesis have been suggested as a reason for reduced breastfeeding rates among women with breast augmentation.16 However, we found that among women who had breast augmentation between births, any breast milk feeding fell from 87% in the “before augmentation” birth to 72% in the “after augmentation” birth, while the rates in comparison groups remained stable. A demonstrated ability to provide breast milk before augmentation surgery suggests that hypoplasia is not the explanation for lower breastfeeding rates among women with breast augmentation. Similar to the one existing population-based study,17 we found no association between breast augmentation and adverse birth outcomes, including preterm birth, small for gestational age, congenital anomalies, neonatal intensive care unit admission or perinatal death.

Lower breastfeeding rates may reflect maternal and family attitudes and expectations, may be a consequence of surgery, or the breast implants may reduce the ability to lactate. Although a variety of health outcomes have been investigated among women who have silicone breast implants, and their breast milk fed infants, epidemiological studies have not substantiated links with adverse outcomes.18–21 Nevertheless, women with breast implants may fear transmitting silicone or other breast implant materials into breast milk. They may also fear, or have been told by their surgeon, that breastfeeding could undo a satisfactory augmentation result. Another explanation is that lactiferous ducts, glandular tissue or nerves of the breast are damaged during surgery, or by pressure from the implants on breast tissue.22 Furthermore, complications of the surgery including capsular contracture, haematoma formation, infection or pain may reduce the ability or desire to breastfeed.22 Future qualitative research is needed to better understand why women with prior breast augmentation are less likely to breastfeed.

Our findings of reduced rates of any breastfeeding are consistent with the only study that reported rates of any breastfeeding after augmentation among women who attempted breastfeeding.16 However, the latter study reported a stronger effect at 2 weeks postpartum (RR, 0.67; 95% CI, 0.50–0.91). In contrast, our findings differ from the systematic review of three small studies, which found women with breast implants who breast milk fed were less likely to exclusively breastfeed.7 We believe our whole-population findings are more robust. The previous studies had selected populations (eg, lactation referral clients) and variable end points (eg, exclusive breastfeeding, insufficient lactogenesis), used historical controls and made limited attempts to control for potential confounders.7 However, it is possible that differences in the rates of exclusive breastfeeding may become apparent after discharge, as follow-up in the three studies was longer (minimum 2 weeks postpartum).

A strength of our study is the use of recent, large, linked population health datasets that include a third of all births in Australia. Breastfeeding information is reported by a midwife, and previous validation studies show events occurring around birth or immediately postpartum are well reported.12 Longitudinal record linkage allowed the ascertainment of cosmetic breast augmentation surgery. Although a longer lookback period may have increased case ascertainment,23 some missed cases among a population of more than 300 000 women without breast augmentation are unlikely to change the findings. Similarly, women who have cosmetic surgery overseas or interstate are not captured in this study. Identification of breast augmentation surgery in routinely collected data has not been evaluated but, in general, surgical procedures are reliably identified in hospital discharge data, and other breast surgery, such as mastectomy, is accurately reported (sensitivity, 97%; positive predictive value, 97%).12,24

Another strength is that breastfeeding was assessed at the same time for both exposed and unexposed women, unlike prior studies.7 The 89% breastfeeding rate at discharge in our study is similar to the rate reported in the Australian National Infant Feeding Survey (90.2% for < 1 month).25

However, information on breastfeeding initiation was not available. If women with breast augmentation initiated breastfeeding but gave up before discharge, the rate of exclusive breastfeeding could be lower if these women were included in the “any breastfeeding” denominator. Another limitation of the study is that breastfeeding is only assessed at one time point (discharge). Breastfeeding rates decline steadily over the first months of infancy25 and it is unclear whether this decay would be the same for women with and without breast augmentation. Information was not available on intention to breast milk feed, paternal support for breastfeeding, nor on the details of the breast augmentation surgery, such as the incision type or the type and volume of the breast implant.

An absolute rate of one in five women with breast augmentation who subsequently give birth may be unable or unwilling to breast milk feed their infants. This information should be provided as part of informed decision making to women contemplating breast augmentation surgery.

1 Study population flowchart, 2006–2011

2 Maternal, pregnancy and birth characteristics for participants, by breast augmentation status

 

Breast augmentation (n = 892), no. (%)

No breast augmentation (n = 377 497), no. (%)

P*

Mother’s age at birth (missing = 106)

    

< 0.001

< 20 years

3 (0.3%)

15 406 (4.1%)

  

20 to < 35 years

608 (68.2%)

276 043 (73.2%)

  

≥ 35 years

281 (31.5%)

85 942 (22.8%)

  

Region of birth (missing = 1489)

    

< 0.001

Australia or New Zealand

761 (85.5%)

264 041 (70.2%)

  

Asia

45 (5.1%)

58 811 (15.6%)

  

Other

84 (9.4%)

53 158 (14.1%)

  

Married or de facto

718 (80.5%)

308 709 (81.8%)

0.32

Socioeconomic status (missing = 6140)

    

< 0.001

Most disadvantaged

103 (11.6%)

79 232 (21.3%)

  

Disadvantaged

134 (15.1%)

71 517 (19.3%)

  

Average

159 (17.9%)

75 027 (20.2%)

  

Advantaged

210 (23.7%)

71 656 (19.3%)

  

Most advantaged

282 (31.8%)

73 929 (19.9%)

  

Urban residence at birth

653 (73.2%)

263 218 (69.7%)

0.02

Private care

370 (41.5%)

120 211 (31.8%)

< 0.001

Nulliparous

378 (42.4%)

206 078 (54.6%)

< 0.001

Multifetal pregnancy

18 (2.0%)

5282 (1.4%)

0.12

First antenatal visit < 20 weeks’ gestation

834 (93.5%)

344 892 (91.4%)

0.02

Smoking during pregnancy

85 (9.5%)

45 073 (11.9%)

0.03

Hypertensive disorders

70 (7.9%)

38 568 (10.2%)

0.02

Diabetes

32 (3.6%)

26 621 (7.1%)

< 0.001

Morbid obesity

0

1277 (0.3%)

0.08

Regional labour analgesia

284 (31.8%)

101 925 (27.0%)

0.001

Labour induction

256 (28.7%)

103 368 (27.4%)

0.38

Mode of birth (missing = 287)

    

0.62

Unassisted vaginal

485 (54.4%)

210 506 (55.8%)

  

Instrumental vaginal

130 (14.6%)

51 447 (13.6%)

  

Caesarean section

276 (31.0%)

115 258 (30.6%)

  

Severe maternal morbidity

12 (1.4%)

6102 (1.6%)

0.52

Mother’s postnatal length of hospital stay

    

0.78

1–2 days

327 (37.2%)

132 944 (35.7%)

  

3–4 days

359 (40.8%)

157 913 (42.4%)

  

5–6 days

168 (19.1%)

70 634 (19.0%)

  

≥ 7 days

25 (2.8%)

10 869 (2.9%)

  

Preterm birth (< 37 weeks’ gestation)

61 (6.8%)

21 871 (5.8%)

0.18

Small for gestational age

75 (8.4%)

35 722 (9.5%)

0.28

Neonatal intensive care unit admission

119 (13.3%)

53 510 (14.2%)

0.48

Major congenital anomalies

36 (4.0%)

13 842 (3.6%)

0.50

Perinatal mortality

0

8

0.89

Infant feeding at discharge

      

Any breast milk feeding

705 (79.0%)

334 250 (88.5%)

< 0.001

No breast milk feeding (formula only)

187 (21.0%)

43 247 (11.5%)

  

Exclusive breast milk feeding among women who provided any breast milk

653 (92.6%)

308 552 (92.3%)

0.76

Breast-related readmission within 6 weeks

13 (1.4%)

4471 (1.2%)

0.42

* χ2 test.

3 Breast milk feeding outcomes for women with two births, showing the before-and-after effect of breast augmentation, 2006–2011

Your AMA Federal Council at work – 7 April 2015

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

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

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

 

The world we live in

Among the great mysteries of human existence, our uncertain relationship with our environment has been a constant source of puzzlement. In the days of the flat earth, when gods and planets needed constant placation and sacrifice lest the food supply fail and fertility fall, surging infections were thought to be a further manifestation of divine displeasure — something that the deities inflicted upon the people (demos) from above (epi) to chasten and punish. Yet the Old Testament book of Leviticus shows that, thousands of years ago, the need to quarantine people with rashes or swellings “like the plague of leprosy” was recognised (Leviticus 13: 2–5), implying that humans understood from early on that they had a measure of control over infective afflictions.

The path from primitive ignorance and fear to the understanding of the microbiological cause of infection is, as the cliche runs, history. Nevertheless, we continue to fear uncontrolled epidemics, despite our heavy investment in technology to hold them at bay.

Battling the threats

At the beginning of 2003, during the early phases of the severe acute respiratory syndrome (SARS) epidemic, I saw lights burning in the windows of Ian Lipkin’s microbiology laboratory at Columbia University, close to where I was working at the time, for 24 hours every day during the race to sequence the genome of the virus responsible. By May, the 29 751-base genome of the Tor2 isolate had been sequenced in British Columbia and published in Science.1 Fortunately, although SARS was a serious illness, as classical epidemiological data were assembled we recognised that it had low infectivity. We had come to know the enemy — quickly and in fastidious detail — yet we still needed traditional methods to prevent its spread.

Infection retains its character of surprise. Who would have guessed the story of Helicobacter pylori and peptic ulcers? As an intern in 1966–1967, peptic ulcer meant antacids, stress and socioeconomic status, vagotomies, pyloroplasties and heroic surgery for life-threatening haematemesis. What other disorders — cancer, coronary disease — may have an infective element in their aetiology? And, like the global financial crisis of 2008, the Ebola epidemic of 2013 caught us off guard. It also reminded us of how critical the social environment and poverty, in particular, are to the formation of modern infective epidemics.

Complex relationships

In recent years, dramatic developments in our exploration of the universe of infection have led us to the human microbiome — the “organ” that has 10 times as many cells as does the whole of the rest of the human body — that inhabits our gut, skin and other surface tissues, and about which new knowledge is coming to us daily. A 2012 Spanish study described a changing microbiome profile in human breast milk over the months after birth that involved over 700 species of microorganisms.2

I had a glimpse of the importance of the human microbiome in 1968 when working at Baiyer River in the western highlands of Papua New Guinea. We were visited by Eben Hipsley, a nutrition scientist from Canberra, who had an interest in understanding how the local Enga people, naturally muscular and fit, kept their metabolism going without eating much more than sweet potato.3 What about essential amino acids? In private conversation, Eben conjectured that their gut flora generated the molecules missing from this people’s natural diet. Today’s experts in this field presumably have a much better idea of Papua New Guinean nutrition, but Hipsley respected what he knew, even then, of the human microbiome. Contemporary experts now agree that while human microbiota do not fix atmospheric nitrogen, they can upgrade dietary nitrogen-containing compounds into essential amino acids.4

Together, we triumph

In terms of infection control, the global response to HIV has been an astounding exercise that combined technology, preventive science, biological insight, social understanding, philanthropy and dogged global political action. This, together with the GAVI Alliance (made up of such heavyweights as the World Health Organization, UNICEF, the World Bank, the Bill & Melinda Gates Foundation and donor countries), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the elimination of smallpox, should surely give heart to those who doubt the value of medical research and action. Rather than lamenting what we can’t do, these achievements signal what amazing things we can do together when we try.

Wasteful overinvestigation — ultrasound in groin hernias and groin pain

To the Editor: Surgeons detest the waste involved in routine ultrasounds for all patients with groin hernias and those with groin pain only.

An inguinal hernia is a groin swelling with a cough impulse, clinically obvious in nearly all patients. No additional value is obtained from an ultrasound, which does not change the management.

In addition, nearly all patients with groin pain without any noticeable swelling are now unfortunately appearing with an ultrasound “diagnosing” a hernia. Pain is often exercise-induced, felt in the inner thigh, and often present at night or when rolling over in bed. The ultrasound report will invariably declare “there is an indirect inguinal hernia containing fat” (sometimes the fat is labelled omentum). Commonly this is embellished with “a neck of 4 [or 6 or 8] mm”.

Unfortunate consequences ensue from mislabelling a mobile blob of fat protruding through the deep inguinal ring as an indirect hernia. The ultrasound, the second general practitioner visit and the surgeon’s visit add to delay and cost, and the true musculoskeletal, or occasionally neurogenic, cause of the groin pain is not assessed and treated.

The ultrasound report not infrequently leads to totally unnecessary surgical exploration of the groin to cure the “inguinal hernia”. The original musculoskeletal cause of groin pain persists, leading to prolonged incapacity and sometimes a chronic pain syndrome. Complications of hernia surgery or mesh are blamed for the continuing pain; this often results in a degree of permanent impairment, and litigation.

There are a few useful indications for groin ultrasounds. They can help to exclude recurrent herniation. They may also detect a narrow-necked hernia in the rare but classic patient with an intermittently presenting, reducible groin swelling. An ultrasound can help to exclude a direct hernia defect plugged with fat in a patient with groin pain on sitting, no musculoskeletal pain source and no detectable clinical hernia. Ultrasound can also be used to determine whether a fixed solid groin lump is an incarcerated hernia or a lymph node.

Otherwise, time and money should not be wasted on unnecessary groin ultrasounds.

Sentinel lymph node biopsy for melanoma: an important risk-stratification tool

In reply: We thank Zagarella and colleagues for their comments and the opportunity to correct some misconceptions about the Multicenter Selective Lymphadenectomy Trial-1 study.1

It is unclear why they have taken exception to the reporting of disease-specific survival as this is a more robust end point than overall survival and, in this patient cohort (median age, 52 years), the two outcomes are likely equivalent.

The subgroup analysis of patients with lymph node involvement was preplanned, and the novel and robust statistical method (latent subgroup analysis) showed improved outcomes with early intervention for node-positive patients. This finding is intuitive, and Zagarella and colleagues provide no evidence as to why they consider this “unreliable”.

Sentinel lymph node biopsy (SLNB) has repeatedly been shown to be the most significant independent predictor of survival in clinically lymph node-negative patients, including by Mitra et al,2 also cited by Zagarella and colleagues. The use of ultrasound or other clinicopathological algorithms have not been reproducible and cannot be used a surrogate.3

Until a better test is developed, SLNB remains the gold standard staging test for clinically lymph node-negative patients with intermediate thickness melanoma.

[Review] Essential surgery: key messages from , 3rd edition

The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015–16. Volume 1—Essential Surgery—identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume’s five key findings. First, provision of essential surgical procedures would avert about 1·5 million deaths a year, or 6–7% of all avertable deaths in low-income and middle-income countries.