more_vertSince its introduction nearly 100 years ago,1 arthroscopy of the knee has revolutionised the care of patients with meniscal lesions, ruptures of the anterior cruciate ligament, and cartilage damage. Although knee arthroscopy has proved to be an asset that is highly beneficial to many patients, it is not a panacea for all knee problems. The clinical benefit is especially questionable for patients with degenerative osteoarthritis: in a trial using a sham surgery,2 knee arthroscopy had no effect, and this finding was confirmed in another study.
Preference: Surgery
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[Editorial] Facial injuries
Patients, surgeons, and other health-care professionals met to discuss life after facial injuries at an event on Jan 22 organised by the Royal Society of Medicine and Saving Faces, the facial surgery research foundation. A large proportion of facial injuries result from interpersonal violence, in which the maxillofacial region is frequently targeted. In domestic violence, damage can be very severe due to extreme violence and protracted uninterrupted attacks. In trauma cases, facial injuries are often a sign of extensive injuries and many patients experience associated head injury.
Long-term plan lacking in private health insurance
The AMA continues to be at the forefront of the campaign for better products from the private health insurance sector, repeating its warning that any increase on a product that is not offering value to its consumers has got to be a concern.
Following the Federal Government’s assurance that Australians would get the lowest insurance premium increase in more than a decade, albeit at double the rate of inflation, AMA Vice President Dr Tony Bartone undertook a number of media interviews to stress that the AMA had been asking for better value products, not products that actually increase in cost.
“Consumers and patients alike are making decisions based on information, and then purchasing products and then finding they’re not covered for what they thought they were covered for,” Dr Bartone told the ABC.
“Or there are exclusions or restrictions on those policies. We need better value in those products before we can talk about any increase. We need sustainable private health insurance, and if consumers are making decisions to opt out based on further increases on a product that they see of little or no value, well, that’s only bad for the health industry as a whole.
“There are so many tens of thousands of policies out there. It’s extremely confusing. You’d need a double degree to actually work through all that, and then at the end of the day, you still might not be correct.
“There is a review, there is a roundtable at the moment, but we need all parties to get together and to come out with a process that actually makes it very clear to the consumers what they’re getting, that offers them value for money, and offers them an insurance that gives them the cover they need, when they need it.”
The cost of private health insurance is set to be the lowest hike in more than 15 years, with the average increase to be about 3.9 per cent.
The premium changes come into effect on April 1 and will represent a rise that is double the inflation rate.
The average family can expect to pay more than $150 a year extra on hospital cover.
The announcement comes at a time when more Australians are opting out of private health insurance.
“No doubt many are opting out because of a bad experience,” Dr Bartone said.
“They’ve come to use their product that they’ve been paying for for many, many years, and then find, when the crunch comes, they’re not covered or they’re significantly out of pocket.
“This is about ensuring the long-term viability of the private health insurance area to make sure that we’re taking the burden off the public hospital system. A necessary part. The two work hand-in-hand, like hand in glove, and we need a really good functioning private hospital area to take the burden, another option.
“The vast majority of elective surgery happens in private hospitals, and we need people not to opt out but we need them to maintain it. And where people have the ability, they should be facilitated in making that decision to keep that.”
Dr Bartone said it was not a question of criticising the private health insurance sector, but about making it very clear that more needs to be done.
“Everyone’s at the table, everyone has their specific little wish list or agenda, but we need to make sure that the Australian public, the Australian patients, are getting value for money,” he said.
“They’re the ones at the end of the day that are left holding the baby… and they need value for money. We don’t need them opting out because that’s, as I say, bad for everybody.”
The AMA has called for a simplification of the policies into gold, silver, or bronze, so consumers know exactly if they are getting a premium product, a middle of the road, or another product.
“We don’t need products that all they do is deliver a tax deduction and offer you nothing other than just a public hospital treatment,” Dr Bartone said.
“That’s in nobody’s interest. Junk policies do no consumer and no patient any worthwhile benefit, and we need to ensure that there is that clarity. And our gold, silver, bronze allocation with some having no excesses or no exclusions or no restrictions and others having a combination – that’s very clear, is in everybody’s interest.
In a subsequent doorstop media conference, Dr Bartone said the announcement of increases in private health insurance was concerning because the increases were not being matched by increasing value.
“Right along we’ve said that private health insurance needs to deliver more value to patients, more value to consumers, to make their products both affordable and attractive,” he said.
“Every day, Australians are making decisions to opt out of private health insurance. These increases will only bring that question even further into light. We need to ensure that Australians keep their private health insurance, because the private health system delivers significant benefits to the entire health system.
“It takes the pressure off the public health system, and any decision of Australians to continue to opt out of private health insurance will only put pressure on an already overburdened public hospital system.”
Dr Bartone said consumers must take particular note of the fine print of private health insurance premiums.
“It’s the exclusion for this particular surgery or that particular surgery,” he said.
“Pregnancy, for example, is not covered in a majority of policies and that in itself is a concern, when a vast number of the many thousands of pregnancies are unplanned, and leaving people having to make decisions then.
“It’s about understanding that across all those things.”
CHRIS JOHNSON
[Articles] Daytime variation of perioperative myocardial injury in cardiac surgery and its prevention by Rev-Erbα antagonism: a single-centre propensity-matched cohort study and a randomised study
Perioperative myocardial injury is transcriptionally orchestrated by the circadian clock in patients undergoing aortic valve replacement, and Rev-Erbα antagonism seems to be a pharmacological strategy for cardioprotection. Afternoon surgery might provide perioperative myocardial protection and lead to improved patient outcomes compared with morning surgery.
[Comment] Tranexamic acid: is it about time?
For decades, the antifibrinolytic drug tranexamic acid has been used for indications such as dental extractions in patients with haemophilia. Additionally, tranexamic acid has been widely used, although not routinely across the world, to reduce blood loss in surgery. More recently, the potential of tranexamic acid in trauma and post-partum haemorrhage has been of interest.1 In two large, randomised controlled trials, CRASH-22 and WOMAN,3 tranexamic acid reduced mortality from bleeding in patients with these conditions.
The horror of waking up during surgery
The fear of waking up while you’re being operated upon is almost up there with the fear of being buried alive. But while the latter never happens any more, if it ever did, the former is more common than you might think. A newly published review reveals that accidental awareness during general anaesthesia (AAGA) may occur in one in every 800 interventions, depending on how you define the term. And some level of responsiveness during surgery could happen in as many as one in 25 cases.
Waking up during surgery is often, understandably, a traumatic experience. Take the case of Sandra, who as a 12-year-old suffered an episode of AAGA during a routine orthodontic operation.
“Suddenly, I knew something had gone wrong,” Sandra wrote in the foreword to NAP5, a recent UK report on AAGA. “I could hear voices around me, and I realised with horror that I had woken up in the middle of the operation, but couldn’t move a muscle… while they fiddled, I frantically tried to decide whether I was about to die.”
Like many other victims of AAGA, Sandra suffered from PTSD-like symptoms for years after the event. She described nightmares in which “a Dr Who-style monster leapt on me and paralysed me.” The nightmares continued for more than 15 years before she realised the link: “I suddenly made the connection with feeling paralysed during the operation; after that I was freed of the nightmare and finally liberated from the more stressful aspects of the event.”
The account underlines a key factor in AAGA, which is the use of neuromuscular blocking agents as part of the anaesthetic mix. They paralyse the muscles, which means that if a patient wakes up for any reason, he or she cannot signal to the surgeon that anything is wrong. It can render AAGA a truly terrifying experience, during which patients can hear voices and equipment, and vainly try to move to alert staff as a feeling of dread and powerlessness sweeps over them.
The NAP5 report found that anaesthesia awareness was most common in obstetrics, and specifically in caesarian interventions. This could be because caesarians often require rapid induction of anaesthesia, with anaesthetists occasionally erring too greatly on the side of caution with doses that are too low.
Cardiothoracic surgeries also had a higher rate of AAGA, at around twice the rate of other surgeries.
Female gender, youth, obesity, a junior trainee anaesthetist and the use of neuromuscular blockades were found to be the key risk factors for AAGA.
Around 40% of victims of AAGA reported ongoing adverse effects, including nightmares, flashbacks and other PTSD-type symptoms.
The review authors say that although in many cases the cause of AAGA is obvious, involving technical failure or error, there remain cases where no rational explanation can be found. But although case reports of AAGA can make for harrowing reading, litigation is relatively rare. In the UK between 1995 and 2007, only 99 claims were made for intraoperative paralysis or brief awake paralysis.
When AAGA is reported, the authors recommend three stages of management: a meeting and interview with the patient; analysis of what went wrong; and follow-up interviews 24 hours and two weeks after the event.
It’s important that the interviewing clinician shows empathy, accepts the AAGA story as genuine, expresses regret, and offers psychological support to the patient.
You can read the review here.
[Comment] Circadian rhythm and ischaemia–reperfusion injury
Every day, thousands of patients are exposed to ischaemia-reperfusion injury, either in uncontrolled circumstances (eg, acute myocardial infarction or ischaemic stroke) or under controlled conditions (eg, heart, kidney, or liver surgery, or transplantation). Whatever the clinical setting is, the extent of final tissue damage (ie, infarct size) is mainly determined by the duration of the ischaemic phase and the amount of jeopardised tissue.1 Experimental and proof-of-concept clinical trials have shown that infarct size results from the addition of an ischaemia-induced injury plus a reperfusion-induced injury, and that timely interventions might attenuate the latter.
[Perspectives] Hospital histories
We never quite know what goes on behind closed doors. Hospitals are incubators for the most vital and vivid of human interactions. Much of these are secret and enclosed, sealed against the outside world. We are stripped down, as patients, wheeled on a trolley for surgery, our flawed and faulty bodies all we are left with. We become reliant on others to fulfil our basic bodily functions. Often dependant and frightened, patients are ministered to by staff, who also come with their own needs, anxieties, and dysfunctions.
Coordinated approach needed to improve Indigenous ear health
Ear health is the focus of the 2017 AMA Indigenous Health Report Card, with doctors calling on all Governments to works towards ending chronic otitis media.
Releasing the Report Card in Canberra on November 29, AMA President Dr Michael Gannon challenged the Federal Government and those of the States and Territories to work with health experts and Indigenous communities to put an end to the scourge of poor ear health affecting Aboriginal and Torres Strait Islanders.
The Report’s focus on ear health was part of the AMA’s step by step strategy to create awareness in the community and among political leaders of the unique health problems that have been eradicated in many parts of the world, but which still afflict Indigenous Australians.
“It is a tragedy that in 21st century Australia, poor ear health, especially chronic otitis media, is still condemning Indigenous people to a life sentence of hearing problems – even deafness,” Dr Gannon said.
“Chronic otitis media is a disease of poverty, linked to poorer social determinants of health including unhygienic, overcrowded conditions, and an absence of health services.
“It should not be occurring here in Australia, one of the world’s richest nations. It is preventable.
“Otitis media is caused when fluid builds up in the middle ear cavity and becomes infected.
“While the condition lasts, mild or moderate hearing loss is experienced. If left untreated, it can lead to permanent hearing loss.”
Dr Gannon said that for most non-Indigenous Australian children, otitis media is readily treated, but for many Aboriginal and Torres Strait Islander children, it is not.
Estimates show that an average Indigenous child will endure middle ear infections and associated hearing loss for at least 32 months, from age two to 20 years, compared with just three months for a non-Indigenous child.
The Report Card, A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities, was launched in Parliament House by Indigenous Health Minister Ken Wyatt
Mr Wyatt commended the AMA on its 2017 Report Card.
Over the past 15 years, he said, the AMA’s annual Report Card on Indigenous Health has highlighted health priorities in Australia’s Aboriginal peoples and communities.
“Reports can be daunting and they can be challenging,” the Minister said.
“But above all, they can be inspiring.”
Mr Wyatt said it was a tragedy that the most common of ear infections and afflictions were almost entirely preventable.
Yet left untreated in Indigenous children, they had lifelong effects on education, employment and well-being.
“It’s not somebody else’s responsibility. It’s the responsibility of all of us,” he said.
“Hearing is fundamental.”
Shadow Indigenous Health Minister Warren Snowdon also commended the AMA on its report.
He said the Government and the Opposition worked collaboratively on Indigenous health issues.
“We’re not interested in making this a point of political difference, we’re interested in making it a national priority,” he said.
Green’s Indigenous Health spokeswoman Senator Rachel Siewert welcomed the Report and stressed the importance of addressing Indigenous health issues.
Australia’s first Indigenous surgeon, ear, nose and throat specialist Dr Kelvin Kong, who is also the Chair of the Australian Society of Otolaryngology Head and Neck Surgery’s Aboriginal Health Subcommittee, received the report with enthusiasm.
He said cross-party support on this issue had been “phenomenal”.
Dr Gannon said the AMA wants a national, systematic approach to closing the gap in the rates of chronic otitis media between Indigenous and non-Indigenous infants and children in Australia.
The Report calls on Governments to act on three core recommendations: namely, that a coordinated national strategic response to chronic otitis media be developed by a National Indigenous Hearing Health Taskforce under Indigenous leadership for the Council of Australian Governments (COAG); that the wider impacts of otitis media-related developmental impacts and hearing loss, including on a range of areas of Indigenous disadvantage such as through the funding of research as required are addressed; and that attention of governments be re-directed to the recommendations of the AMA’s 2015 Indigenous Health Report Card, which called for an integrated approach to reducing Indigenous imprisonment rates by addressing underlying causal health issues.
“We urgently need a coordinated national response to the lasting, disabling effects and social impacts of chronic otitis media in the Indigenous adult population,” Dr Gannon said.
The AMA Indigenous Health Report Card 2017 A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities can be found at article/2017-ama-report-card-indigenous-health-national-strategic-approach-ending-chronic-otitis
CHRIS JOHNSON
OPINION – Can safer surgery be legislated?
BY DR PETER SUBRAMANIAM
In June, a Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality report sparked Queensland government action that may trigger new federal and state laws for public reporting of patient safety data across public and private hospitals. By August, Queensland had released a discussion paper and its push for such standards nationally was supported by federal and state health ministers at COAG Health Council. The Council tasked the Australian Commission on Safety and Quality in Health Care to work with ‘interested jurisdictions’ on such standards and to incorporate the work into national performance and reporting frameworks.
Compliance with audits of surgical mortality like the Queensland report is a mandated professional practice requirement for all surgeons while all public hospitals and almost all private hospitals already participate in the audits. So, the question doesn’t appear to be hospitals’ compliance with public reporting of performance data on patients admitted to hospital under a surgeon. The relevant questions seem to be what constitutes metrics of patient safety-oriented surgical performance and whether legislation can protect patients’ safety.
What are the metrics of patient safety-oriented surgical performance?
Patients admitted under a surgeon in a hospital are treated by a surgical team regulated by the hospital’s organisational framework that is part of a public or private hospital network. So, correctly, the metrics of patient safety-oriented surgical performance are metrics of the effectiveness of both surgical team performance and organisational performance of the hospital and its parent organisation. Only if both sets of metrics are reported will the public be fully informed about whether the hospital, public or private, is effective at protecting their safety.
This concept of patient safety-oriented surgical performance is backed by evidence. Patient safety depends on effective surgical team communication and adverse events by individual surgical team members are typically rooted in faulty systems and inadequate organisational structures. This evidence is reflected in local experience of more than 33,000 cases over eight years reported in the Australian and New Zealand Audit of Surgical Mortality National Report 2016. Its key points include that surgical team communication is a key element of good patient care and delayed inter-hospital transfers of patients with limited reserves can significantly affect surgical outcomes.
So, metrics of patient safety-oriented surgical performance must show effective surgical team communication as being timely decisions and actions to prevent, diagnose and treat surgical complications and deteriorating patients e.g. prompt resuscitation and surgery for postoperative bleeding. Likewise, such metrics must also show effective hospital and parent organisational systems enabling surgical teams’ decisions in a way that protects patient safety e.g. prompt inter-hospital transfers, timely ICU bed and OR access, safe working hours and staff levels.
Can legislation protect surgical patient safety?
The results of the Australian and New Zealand Audit of Surgical Mortality suggest surgical patient mortality represents a segment of Australia’s aging population who are at the extreme of life with co-morbidities that are a stronger predictor of death than the type of surgery. When an acute surgical condition supervenes, they have a rapidly shrinking window of opportunity with almost a quarter being irretrievable. They are prone to surgical complications which often leads to cardiac or respiratory failure with rapid deterioration and death. Nonetheless, surgical mortality in Queensland and nationally has been improving over the last eight years so it is difficult to envisage how new legislation will add much to improving surgical patient safety.
Is legislation necessary?
In 2016, a number of NSW private hospitals did not participate in the audit of surgical mortality despite compliance by all public and private hospitals in all other jurisdictions through the system funded by all State and Territory Governments. If legislation is to bring private hospitals in line with this public reporting system, it should be directed specifically for this reason. If it is to improve surgical patient safety or to inform patient choice, it is not clear how it will improve on the current public reporting system supported by governments. If a national performance and reporting framework is being developed, it should be directed at metrics of surgical team and organisational performance.
It remains to be seen if Government will be surgical in its approach to patient safety.
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Dr Peter Subramaniam MBBS MSurgEd FRACS is a cardiothoracic surgeon in Canberra who is currently pursuing a Juris Doctor law degree at the Australian National University. He established the Australian and New Zealand Cardiac and Thoracic Surgeons national cardiac surgery database in the ACT as well as the multidisciplinary ACT Cardiac Surgery Planning Group. He also has extensive experience in undergraduate and postgraduate surgical education.
Views expressed in the opinion article reflect those of the author and do not represent official policy of the AMA.