[Comment] Is organ preservation in rectal cancer ready for prime time?

Each year, over 8500 patients in the UK are diagnosed with rectal cancer. Preoperative chemoradiotherapy followed by surgery reduces the risk of local recurrence by downstaging the tumour and results in cure for many patients.1,2 In 2004, Angelita Habr-Gama and colleagues3 reported their results based on 10 years of experience of avoiding surgery after chemoradiotherapy in patients with clinical complete response (cCR). Instead of surgery, they successfully performed clinical surveillance by endoscopy and digital rectal examination.

How old is too old for surgery, and why?

Many of us will have been in situations with older loved ones where a doctor says surgery is too risky given the patient’s advanced age. Why is it surgery becomes risky in the elderly, and is it based on chronological age or their health?

During surgery and anaesthesia, there are many changes in the body that occur in response to injury and trauma. This is known as the stress response to surgery.

The surgical stress response results in an increased secretion of hormones that promote the break down of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery. The hormonal changes associated with the surgical stress response also activate the sympathetic nervous system.

The sympathetic nervous system is responsible for the “fight or flight” response and causes a rise in heart rate and blood pressure. The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impedes the oxygen supply to the vital organs such as the heart and the brain. This is a result of less blood flow to the body organs during and after the operation.

Anaesthesia confers risks separate from the risks of surgery. These are mostly minor and easy to treat. But serious problems with the heart, lungs and other major organs are more likely during emergency surgery or in the presence of other health conditions. These factors may increase with chronological age, but frailty is the bigger factor for doctors in deciding whether a patient should undergo surgery and anaesthesia.

Frailty

Frailty is a state where a person is vulnerable due to decline in body function. This in turn reduces their ability to cope with acute and every day stressors.

In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure. The organ systems near the threshold of failure are then unable to “bounce back” from an external or internal stressor.

An apparently small insult such as a simple fall can result in a significant and disproportionate reduction in reserve and function. The need to have surgery, and the condition that has caused a need for surgery, would often be considered a large insult in a frail person.

Although frailty is more common in older people, it’s not exclusive to older people. Most frail people have chronic health problems, and their frailty increases with the number of chronic health conditions. But most people with chronic health conditions are not frail.

There are certain health conditions that are more common in people who are frail, such as heart failure, chronic airways disease and chronic kidney disease.

How do we identify frailty and how does it affect health?

There are many different tools we can use to detect frailty. The Clinical Frailty Scale is one tool based on clinical features present in the patient and the Frailty Index is another tool based on the accumulation of deficits in the patient.

The Clinical Frailty Scale is a single descriptor of a person’s level of frailty using clinical judgement graded from one to nine. Level one is a very fit person; level four is “vulnerable” – where the person is not dependent on others for help with daily activities but does have symptoms that limit activities; and level nine is a terminally ill person.

It has been observed that people with a higher Clinical Frailty Scale were more likely to be older, female, have a degree of cognitive impairment and incontinence. The higher proportion of females will most likely reflect the longer life expectancy of women.

Frail people have a higher risk of recurrent falls and fractures and subsequent disability and reduced function. There have been many studies performed to examine how well frailty predicts outcomes after surgery.

In people who have surgery, frailty has been shown to be associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk the patient will require readmission after surgery, and the higher the risk of death.

As our population gets older and more frail people have surgery, this will become an important issue, and health care professionals in all areas will need to be more aware of it.

Juliana Kok, Clinical Lecturer and anaesthetist, University of Melbourne

This article was originally published on The Conversation. Read the original article.

[Comment] Screening men for AAA under magnification loupe in Sweden

Nationwide screening for abdominal aortic aneurysm (AAA) in men has only been implemented in Sweden and the UK. In 2016, the Swedish National Board of Health and Welfare, a government agency under the Swedish Ministry of Health and Social Affairs, re-established its support for the recommendation to screen men aged 65 years with one ultrasound examination of the abdomen,1 stating that on the basis of available evidence, ”the benefits will outweigh the harms”. In The Lancet, Minna Johansson and colleagues2 report estimates of the effect of AAA screening on disease-specific mortality, incidence, and surgery in a real-world setting.

[Series] Prevention and treatment of low back pain: evidence, challenges, and promising directions

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness.

Mr Hunt, are we there yet? Continuing the public hospital funding journey

BY DR RODERICK MCRAE, CHAIR, AMA FEDERAL COUNCIL OF PUBLIC HOSPITAL DOCTORS

By the time of this column’s publication, we may have had some further information from the Federal Minister for Health Greg Hunt, at the AMA’s National Conference, although the Budget is pretty fresh. We know public hospitals are fundamental to Australia’s overall health system, dealing with greater than six million admitted patient care episodes and around 92 per cent of emergency admissions in any one year. Nonetheless, we experience chronic under-funding partially because of near stagnant growth in financial support. This has been going on for just too long; we all feel the pressure day in, day out. We know under-funding is building to crunch point.

AMA’s 2018 Public Hospital Report Card shows bed numbers per 1000 population are static; performance, basically, is plateauing at best; waiting lists, you know the sorry truth about that and our patients are suffering! My December 2017 Australian Medicine column criticised the Council of Australian Government’s (COAG) savage imposed financial penalties where avoidable re-admissions or hospital-acquired complications are deemed to have occurred. The AMA’s 2016 Safe Hours Audit shows that in public hospitals, 53 per cent of doctors are at “significant risk” of fatigue with dangerous fatigue levels being reported across a raft of specialty groups.

So, the effect of underfunding is cumulatively adding up to seriously affecting our, and the system’s, ability to perform optimally for our patients, and our own health and wellbeing is at stake. That’s why the 2018 Budget decisions matter; it’s about what the future holds for public hospital medicine. Without vital new investment, required infrastructure, and human resource capacity, an appropriate standard of result cannot happen.

Reflecting on AMA’s pre-budget submission, what we have said is that the Budget must fully fund, for the medium to long term, internal capacity building and expansion of their integrated care responsibility. Not to penalise an already underfunded sector via that sneaky COAG device that will redirect otherwise committed funds. The AMA also says States and Territories must be fully compensated for any loss in private patient revenue and any funding decisions must not dilute support for patients electing private treatment. Mr Hunt has said he intends to look at these private patient issues so we don’t yet know where Government is headed.

Despite the known pressure on public hospitals the new 2020-25 Hospital Funding Agreement ratchets up this financial pressure on hospitals even further. Within existing levels of Federal funding, the Agreement will require public hospitals to implement new measures to cut waste, increase productivity and extend their responsibilities to engage in the care of chronically ill-patients post discharge to reduce overall admissions.

I agree integrated care is essential – but this work requires new Federal funding to pay for the hospital and primary sector resources required to deliver it. The public hospital funding in the 2018 Federal Budget was nothing more than the amount forecast over the forward estimates to maintain funding at current levels.

There are many laudable new funding initiatives out of this Budget, to name some: a rural doctor workforce/training package, increased support for aged care in the home, and mental health/suicide prevention services, new research investment and (perhaps laughable!) the “unfreezing” of Medicare indexation. However, the Budget lacks consideration of how any savings from the Government’s yet to be finished MBS reviews will be re-invested into public health, and we still wait on needed big structural reform. There must also be funds to urgently begin development of a national medical workforce strategy. On that, your Council of Public Hospital Doctors is working through the AMA to encourage all jurisdictions to cooperate more closely in their planning and coordinating of our future medical workforce to meet Australia’s future healthcare needs.

There’s an election coming; maybe this year; and Labor has promised an additional $2.8 billion ‘better hospitals’ fund to target reducing elective surgery waiting times and increasing emergency department bed numbers. Your CPHD will be looking to score both major parties as they release more health policy and keep a watching on eye on any moves to change public hospital private practice arrangements. We must push for the government to match Labor’s pledge and make Government fund for growth, not just, as it has been, keeping pace with activity. It’s matching funding with growth and having a workforce plan that really matters!

AMA ramps up its aged care advocacy

BY DR ANDREW MULCAHY, CHAIR, AMA’S MEDICAL PRACTICE COMMITTEE

It only takes a skim of the media headlines to know that the aged care system is failing older people. Many reported cases of poor quality care are a result of delayed medical care and neglect, and AMA members are deeply concerned for their older patients. There have been multiple inquiries and reviews into the system in the past couple of years. Government are well aware of the issues and, while there was a $5 billion funding increase in the aged care 2018-19 budget, more urgently needs to be done.

The AMA is responding to its members’ concerns by ramping up its aged care advocacy. In November 2017, the Medical Practice Committee (MPC) conducted a survey on AMA member experiences and perceptions of aged care to inform future AMA policy. In April 2018, a new Position Statement, Resourcing aged care was released. This Position Statement focuses on workforce and funding measures required for a good quality aged care system, and draws from the learnings of the aged care survey.

Aged care calls for adequate resourcing to ensure doctors are supported to deliver medical care to their older patients. One such measure includes appropriate remuneration to cover the opportunity cost of leaving a surgery to visit patients in Residential Aged Care Facilities (RACFs). The AMA also advocated for this policy change at the MBS Reviews’ General Practice and Primary Care Clinical Committee (GPPCCC). Dr Richard Kidd (Chair, Council of General Practice) and AMA Federal Secretariat called for increased MBS rebates for GP RACF attendances, telehealth consultation items for GPs, and for the Practice Incentive Program (PIP) Aged Care Access Incentive (ACAI) to remain.

MPC, with input from the Council of General Practice, has lodged six aged care submissions this year alone. These include:

Aged Care Workforce Strategy Taskforce – The Aged Care Workforce Strategy;
Australian Aged Care Quality Agency – Draft Standards Guidance (for the new Aged Care Quality Standards);
House of Representatives Committee on Health, Aged Care and Sport – Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia;
Medical Services Advisory Committee – New mobile imaging services for residential aged care facilities;
Aged Care Financing Authority – Respite Care; and
Department of Health – Specialist Dementia Care Units.

In addition to the House of Representatives Committee on Health, Aged Care and Sport for the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia submission, Dr Tony Bartone and Dr Kidd gave evidence at a public hearing in May. Dr Bartone and Dr Kidd highlighted that AMA members have major concerns that the current aged care system is failing older people, and called for more appropriately trained aged care staff, especially registered nurses, in RACFs. Dr Bartone and Dr Kidd also highlighted that doctors need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care and outcomes for residents.

In addition to the Aged Care Workforce Strategy Taskforce submission, Dr Bartone recently attended both Aged Care Workforce Taskforce Summits. The summits are aimed at engaging stakeholders in developing a strategy for ensuring aged care workforce growth to meet older people’s needs. Dr Bartone highlighted that the current aged care workforce does not have the capacity, capability and connectedness to adequately meet the needs of older people.

MPC aged care advocacy efforts were also reflected in several Budget announcements, including:

the establishment of an Aged Care Quality and Safety Commission ($nil);
investment in rural aged care ($40million);
improvements to My Aged Care website access ($61.7million) and faster Aged Care Assessment Team (ACAT) assessments ($14.8million);
improved access to specialist palliative care services in RACFs ($32.8million);
a new mental health service for older people living in RACFs ($82.5million); and
14,000 additional home care packages (plus 6000 additional packages as announced in the Mid-Year Economic and Fiscal Outlook) ($1.6billion).

However, more needs to be done to ensure older people receive quality care. 20,000 additional home care packages makes a small dent in the 104,602 people currently on the waiting list. The Productivity Commission stated in 2011 that the aged care workforce must quadruple by 2050 to meet demand, but there was no mention of a workforce strategy in the budget. MPC is waiting with bated breath for the Aged Care Workforce Strategy to complete its work (by the end of June 2018).

MPC will continue advocating for a better quality aged care system. 2018 will see the introduction of four additional aged care Position Statements, covering topics such as the health of older people, palliative care, clinical care, and innovation in aged care. So watch this space.

AMA aged care Position Statements and submissions can be accessed through: advocacy/aged-care.

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada [Research]

BACKGROUND:

Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them.

METHODS:

Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models.

RESULTS:

Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery.

INTERPRETATION:

Exact wait times for urgent and emergent surgery can be measured using Canada’s administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

[Comment] Direct oral anticoagulants for postoperative myocardial injury

Myocardial injury after non-cardiac surgery (MINS), detected by elevated troponin measurement, is a common postoperative complication and increases the risk of 30-day mortality by three times.1 In The Lancet, P J Devereaux and colleagues2 report the results of the MANAGE trial, a randomised, placebo-controlled study investigating use of the direct oral anticoagulant dabigatran in 1754 patients with MINS. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS.

[Comment] Hip arthroscopy: an evidence-based approach

It started with the knee, then the shoulder, then the ankle, and now it is the hips’ turn. Instead of open surgery, arthroscopic surgery of the hip joint can be used to repair structural damage. Arthroscopic surgery is considered to be less invasive than an open procedure, and the intact tissues are minimally exposed and not traumatised. This approach can lead to quicker recovery and early return to function and activity, with fewer complications.1 For the hip, arthroscopy spares the cutting of the ligamentum teres and reduces damage to the capsular structures by avoiding dislocation.

[Correspondence] Daytime variations in perioperative myocardial injury

We read with interest the Article by David Montaigne and colleagues1 reporting that among patients having on-pump cardiac surgery for aortic valve replacement, the time of day that surgery is done might affect their tolerance to ischaemia–reperfusion injury. The results are intriguing and we commend the researchers for their comprehensive translational study.