Volume 170 Issue 6

Research Colorectal cancer after open-access colonoscopy: a community and case survey John Croese MJA 1999; 170: 251-254 For editorial comment, see Bolin & Korman Abstract - Introduction - Methods - Results - Discussion - References - Author's Details - - More articles on Gastroenterology Abstract Objective: To evaluate whether colonoscopy protects against subsequent colorectal cancer (CRC). Design: Case and population survey. Setting: Townsville region in northern Queensland, between mid 1985 and January 1998. Subjects: All 8430 patients who underwent 11 148 colonoscopies performed by the author at the Mater Private Hospital (a community-based open-access colonoscopy service) between July 1985 and December 1996; those who were subsequently diagnosed with CRC, to January 1998; and all 476 residents diagnosed with colorectal cancer between 1994 and 1997. Main outcome measures: Age-standardised CRC incidence for 1994-1997 for patients who had had a previous colonoscopy and for the remaining community; Dukes' grade of CRCs. Results: For people aged 50 years and over, the incidence of CRC was significantly lower among those who had had a previous colonoscopy than in the remaining community (1.14 versus 2.31 per 1000 patient-years; P = 0.0046). For people aged 35-49 years, the incidence was 0.35 versus 0.31 per 1000 patient-years (P = 0.86). Thirty-one CRCs developed in 29 people who had had previous colonoscopy; only five of these CRCs were graded Dukes C, with none graded Dukes D. In contrast, almost half the CRCs in the rest of the community were graded Dukes C or D (P < 0.001). All but one of those diagnosed with CRC on repeat colonoscopy had risk factors (personal or family history), and 23 of the CRCs were subclinical, with 20 being diagnosed during surveillance colonoscopy. Conclusions: Patients aged over 50 years who had previously undergone a colonoscopy and ensuing treatment were less likely to be diagnosed with CRC than otherwise expected. Surveillance colonoscopy led to diagnosis of CRCs with lower Dukes grades. Introduction Colorectal cancer (CRC) is the most common internal malignancy and the second most common cause of death from cancer in Australia. CRC incidence in Australia is similar to that in other developed countries,1 but in the US both incidence and mortality are now decreasing.2 This change has been attributed to removal of premalignant polyps, detection of proportionally more early lesions by colonoscopy, and more effective treatment.3 Strategies based on colonoscopic surveillance and targeting people at increased risk of developing CRC are being promoted.3-5 However, colonoscopy, particularly in community-based, open-access practice, has not been shown to reduce CRC mortality. Indeed, although the rate of colonoscopies in Australia has increased fourfold since 1984, the incidence of CRC in New South Wales between 1973 to 1992 continued to increase by 2% per year in men and 0.9% per year in women.6This study aimed to evaluate whether colonoscopy protects against subsequent CRC by comparing CRC incidence and pathological grading between people who have had a previous colonoscopy and the rest of the population in a geographically isolated area. Methods Setting The study was set in Townsville and the surrounding region (defined by the postcodes 4804-4822, 4849 and 4850; Figure 1). Townsville is a regional centre in northern Queensland that provides centralised health services, including colonoscopy, for a population of 198 000 dispersed over 200 000 km2. The nearest alternative colonoscopy services are located at Cairns and Mackay, 400 km distant. Colonoscopy patients Subjects were patients who underwent colonoscopy performed by myself at the Mater Private Hospital, Townsville. All patients who underwent colonoscopy between July 1985 and December 1996 were identified, most from the hospital's detailed computerised records, but some of those examined between 1985 and 1990 from a hospital work ledger which gave only surname and given name. In addition, detailed demographic and clinical information was collected prospectively in a procedural database for all colonoscopy patients from April 1994 to December 1997. Similar information was obtained retrospectively from the case records of 600 randomly chosen patients who underwent colonoscopy between 1986 and 1990. Colonoscopic procedures and surveillance Colonoscopies were performed on patients referred by a general practitioner or specialist either for surveillance or for investigation of symptoms. Through concessions available until mid 1996, the service was equally available to all patients irrespective of financial resources. Fibreoptic colonoscopes were used before 1990, and video colonoscopes after then. Patients were lightly sedated with fentanyl (100 µg) and midazolam (2.5-5 mg). Treatment (eg, polypectomy, CRC resection) was given as necessary. Surveillance recommendations were mostly included in procedure reports and passed to both the patient and the referring doctor. While these recommendations changed over time consistent with published guidelines,3,7 a general summary is: Annual surveillance for either active ulcerative pancolitis of seven years' duration or longer or a previous malignancy plus a family history of hereditary non-polyposis colorectal cancer (HNPCC);3,7 One- to two-yearly surveillance for a previous CRC before 50 years and for those older than 25-40 years with either CRC developing in a first-degree relative before 50 years or a family history of HNPCC; Two- to five-yearly surveillance for longstanding quiescent pancolitis or active limited colitis, CRC or polyps in a first-degree relative, previous CRC, or large (>1 cm diameter) or multiple colonic polyps; and Five- to 10-yearly surveillance, depending on age, for a small adenomatous polyp. Colorectal cancer diagnoses All patients diagnosed with CRC in Townsville between January 1994 and December 1997 were identified retrospectively by searching the computerised databases of all three pathology services, three hospitals, three endoscopy services, three colonoscopists (including myself) and one oncology service provider in Townsville, and from the CRC audits maintained by the six surgeons in Townsville. From 1995, patients diagnosed with CRC were also identified prospectively by clinicians and institutions. Patients diagnosed with CRC who had had a previous colonoscopy performed by myself at the Mater Private Hospital were identified to January 1998. Clinical records of all patients diagnosed with CRC were audited by myself. A modified Dukes classification (A, B, C or D) was used for staging cancer spread.8,9 A malignant polyp was classified separately if colonoscopic resection was regarded as the definitive treatment. In cases of synchronous lesions, the lesion with the most invasive grading was registered. Incidence of CRC Colonoscopy population: The incidence of CRC was calculated as the number of cases per thousand patient-years for the period 1994-1997 for patients who had had a previous colonoscopy and still lived in the region in 1997 (colonoscopy population). Residence was determined from the electoral register current in January 1997,10 which is considered reliable as voter registration is compulsory in Australia. To reduce mismatch errors caused by individuals with identical names, only patients with a known middle name (duplication rate, 0.3%) were cross-referenced against voters who also had a recorded middle name (duplication rate, 1.3%). The number of patients without a middle name who were still resident was estimated and added to the above on the assumption that the proportion still resident would be the same in the groups with and without a known middle name. CRC incidence in each year was calculated for patients who had undergone previous colonoscopy up until the previous calendar year. For example, the incidence of CRC in 1994 was calculated for patients who had undergone previous colonoscopy up to 1993. Age of colonoscopy patients was determined for the year of incidence. The number of patient-years was the total for all patients in a given age range who had previously had a colonoscopy up to 1993, 1994, 1995 and 1996. Community: The incidence of CRC in the remaining population (community) was determined from the number of cases that occurred between 1994 and 1997 in people not registered as a colonoscopy patient per the region's population less the colonoscopy population. Population data were obtained from the August 1996 census undertaken by the Australian Bureau of Statistics.9 Statistical analyses Binary data were compared in two by two contingency tables using chi-squared analyses.12 The age-standardised incidences of CRC in colonoscopy patients versus the community were tested for the hypothesis that the ratios were equal to one.13 Results Colonoscopies From mid 1985 to the end of 1996, I performed 11 148 colonoscopies on 8430 patients (Figure 2). The number increased steadily, from 590 in the 18 months 1985-1986 to 2708 in the two years 1995-1996. The number of repeat colonoscopies increased from 12 (2.0%) in 1985-1986 to 875 (32.3%) in 1995-1996. Clinical and procedural characteristics are summarised in Box 1. Slightly more women than men had colonoscopies. Patients undergoing repeat colonoscopies were an average six years older than those newly referred and were more likely to have had surveillance for increased CRC risk as the primary indication (50.7% of repeat colonoscopies versus 15.0% of first colonoscopies; P < 0.0001). Primary indication also varied with time. For example, an abnormal barium enema was a common indication before 1991 (7.0%), but accounted for few after 1994 (0.3%; P < 0.0001). In contrast, a family history of polyps or CRC accounted for a greater proportion of colonoscopies after 1994 (10.6% of first and 11.2% of repeat colonoscopies) than before 1991 (6.3%; P < 0.0001). From the outset, the caecal completion rate exceeded 95%, and from 1994 it was 98.9% overall and 99.5% in those without a malignant obstruction. Polyps were diagnosed (and removed) in a greater proportion of repeat than first colonoscopies (36.1% versus 29.8%; P < 0.0001). Both these rates were higher than for colonoscopies performed before 1991 (24.5%; P < 0.0001). However, CRC was diagnosed less often in repeat than in first colonoscopies (0.6% versus 2.2%; P = 0.001). Resident populations Complete details, including a middle name, were recorded for 5762 of the 8430 colonoscopy patients (68.4%), and 4200 of these (72.9%) were registered voters and residents of the Townsville region in 1997. A surname and one given name only were recorded for the remaining 2668 patients -- 1913 from the hospital's computer register and 755 from the work ledger. This gave an estimated total number of resident colonoscopy patients of 6195 in 1997. Colorectal cancers Between 1994 and 1997, 476 new CRCs were diagnosed in residents of the Townsville region, with 474 in people aged over 35 years. Eighteen were in patients who had had a previous colonoscopy; each of these was diagnosed per colonoscopy by myself, nine at the study hospital (registered in the procedural database and shown in Box 1), and the remainder elsewhere. Incidences of CRC between 1994 and 1997 are shown in Box 2. In people aged over 50 years, the annual incidence of CRC in the colonoscopy population (1.14) was just less than half that in the remaining community (2.31; P = 0.0046). Between July 1985 and January 1998, I diagnosed 31 CRCs in 29 patients who had had a previous colonoscopy (two patients had a second CRC diagnosed two years after the first in each case). All but one of these patients had a personal or family history that warranted surveillance, and 21 had been enrolled in surveillance programs, with 20 (65%) having had multiple previous colonoscopies (mean, 3.4; range, 2-9). For 20 of the CRCs, planned surveillance was the indication for the repeat colonoscopy. Among the 11 people with symptoms as the primary indication, these symptoms were considered unrelated to the CRC in at least three. The time between most recent previous colonoscopy and diagnosis averaged 37 months (range, 3-136 months). Staging of CRCs is shown in Box 3. Metastatic spread from CRCs was less common in patients who had had a previous colonoscopy than in the community; only five of the 31 cases in colonoscopy patients were graded C, and none were graded D, while 219 of the 458 community cases (48%) were graded C or D (P < 0.001). Among the five colonoscopy patients with metastatic spread (Dukes C), the time between most recent previous colonoscopy and diagnosis was 19, 24, 29, 32 and 70 months, respectively. Discussion The study evaluated a colonoscopic service that followed and promoted contemporary surveillance guidelines similar to those currently recommended by professional cancer and gastroenterological societies.3 The incidence data suggest, but do not prove, that colonoscopic surveillance confers a benefit. Age-standardised incidence of CRC among people aged 50 years and over in the Townsville region was lower among those who had had a previous colonoscopy, along with any treatment considered necessary (eg, polypectomy or bowel resection), than in the community. This was despite the fact that many of those who had had a previous colonoscopy had a personal or family history likely to increase their risk of developing CRC. Furthermore, the CRCs that occurred in those who had had a previous colonoscopy were of a lower Dukes grade than those occurring in the community. The difference in incidence suggests but does not prove that colonoscopy is protective against CRC. CRC incidence for 1994-1997 in those who had had a previous colonoscopy may have been reduced, at least partly, by detection of subclinical CRCs during their pre-1994 colonoscopies. On the other hand, selection bias suggests that these people would develop more CRCs than the general population. The impact of each of these factors could not be measured, and there is no historical benchmark or matched population for comparison of outcomes. However, the result does suggest that colonoscopy confers a benefit, possibly because of removal of polyps and certainly because of detection and treatment of subclinical CRCs. In people aged 35-49 years, CRC incidence in those who had had a previous colonoscopy was similar to that in the community. Without a control group, a benefit of colonoscopy cannot be dismissed, as the colonoscopy group was expected to have higher CRC incidence. However, it is evident that, because of the large number of people aged 35 to 49 years and the low incidence of CRC, surveillance must be targeted to be effective. Polypectomy rate was high, and higher in repeat than in first colonoscopies. This also implies that patients having repeat colonoscopies had increased risk of developing CRC.14 While the high polyp rate may have been due to their older average age,15 the latter would also be expected to increase the CRC rate, which did not occur. Given an expectation that all lesions seen at the previous colonoscopy had been dealt with, this outcome (high polyp versus low CRC rate) validates the selection criteria for surveillance. The higher polypectomy rate after 1994 compared with that before 1990 probably relates to other circumstances, such as a higher caecal completion rate, while both indices probably reflect improved instrument technology. Thirty-one new primary cancers developed in 29 colonoscopy patients, with two-thirds diagnosed by planned surveillance colonoscopy. Metastatic spread occurred in only five of these patients. These findings confirm, firstly, that new CRCs will develop and, secondly, that outcome can be improved through early (subclinical) diagnosis.3,16 The number of cancers diagnosed in patients who had had a previous colonoscopy was of concern and suggested lesions might have been missed in the earlier examination. Colonoscopy, even when performed by an expert, does not identify all small lesions, while adverse conditions sometimes obscure gross pathology.17 Colon morphology, quality of the bowel preparation, instrument capabilities and operator proficiency may also impose limitations.3,18 However, substandard colonoscopy is unlikely to have been responsible. The caecum was reached at a rate exceeding the accepted standard (95%),3 and CRCs were observed in all parts of the bowel, arguing against an operator-dependent blind spot. Possibly, the comparatively large number of CRCs found in people undergoing colonoscopic surveillance was simply the outcome of increasing enlistment of an appropriate, at-risk cohort. Although most sporadic CRCs evolve slowly through malignant transition in a polyp, this sequence is truncated or absent for some sporadic CRCs and for CRCs developing in patients with ulcerative colitis or a genetic predisposition.19 It is unrealistic to imagine that surveillance colonoscopy with polypectomy as necessary will much reduce CRC incidence in such at-risk populations. Indeed, it might conceivably increase apparent incidence by uncovering subclinical CRCs. The results support the current practice of targeting individuals with recognised risk factors for surveillance colonoscopy. However, it is important to explain to patients that surveillance does not provide complete protection and that new CRCs are inevitable. Early diagnosis through repeated testing is the essential component of surveillance-derived protection. References Parkin DM, Pisani P, Ferlay J. Estimates of the world-wide incidence of eighteen major cancers in 1985. Int J Cancer 1993; 54: 594-606. SEER Program (National Cancer Institute). Surveillance, epidemiology, and end results (SEER) program. Bethesda, Md: National Cancer Institute, 1973-1992. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997; 112: 594-642. Bolin TD, Korman MG. How can we reduce the incidence and mortality of colorectal cancer [editorial]? Med J Aust 1997; 166: 175-176. Macrae FA. Screening for colorectal cancer, 1996 [editorial]. Med J Aust 1996; 165: 102-105. Bell JC, McCredie M, Coates MS, Armstrong BK. Trends in colorectal cancer incidence and mortality in New South Wales, 1973-1992. Med J Aust 1997; 166: 178-181. Mecklin J-P, Jarvinen HJ, Peltokallio P. Cancer family syndrome. Genetic analysis of 22 Finnish kindreds. Gastroenterology 1986; 90: 328-333. Astler VB, Coller FA. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg 1954; 139: 846-851. Dunlop MG. Polyps and carcinoma. In: Shearman DJC, Finlayson N, Camillieri, Carter D, editors. Diseases of the gastrointestinal tract and liver. 3rd ed. New York: Churchill Livingstone, 1997: 1399-1448. Australian Electoral Commission. Elector information access system. Electoral roll information for Queensland. Canberra: Australian Electoral Commission, 1997. Australian Bureau of Statistics. 1996 census of population and housing. Community profile, Canberra: ABS, 1996 (Cat. no. 2020.0). Approximate significance for contingency tables. In: Matthews DE, Farewell VT. Using and understanding medical statistics. 2nd ed. Basel: Karger, 1988: 20-66. The binomial distribution. In: Snedecor GW, Cochran WG. Statistical methods. 8th ed. Ames: Iowa State University Press, 1989: 107-134. Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med 1992; 326: 658-662. Williams AR, Balasooriya BAW, Day DW. Polyps and cancer of the large bowel: a necropsy study in Liverpool. Gut 1982; 123: 835-842. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328: 1365-1371. (Published erratum appears in N Engl J Med 1993; 329: 672.) Rex RK, Cutler CS, Lemmel GT, et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24-28. Baille J, Ravich WJ. On endoscopic training and procedural competence. Ann Intern Med 1993; 118: 73-74. Kuramoto S, Oohara T. Flat early cancers of the large intestine. Cancer 1989; 64: 950-955. (Received 1 May, accepted 21 Dec, 1998) Author's Details 42 Ross River Road, Townsville, QLD. John Croese, MD, FRACP, Gastroenterologist. Reprints will not be available from the author. Correspondence: Dr J Croese, 42 Ross River Road, Townsville, QLD 4812. Email: jcroeseATmedeserv.com.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to text Back to text Back to text Back to text Back to text

John Croese

Healthcare Acupuncture in Australian general practice: patient characteristics Gary Easthope, Gerard F Gill, Justin J Beilby and Bruce K Tranter MJA 1999; 170: 259-262 For editorial comment, see Bensoussan See also Acupuncture in Australian general practice: practitioner characteristics Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Complementary medicine Abstract Objective: To ascertain the incidence of acupuncture claims and the characteristics of patients claiming for acupuncture. Design: Secondary analysis of Health Insurance Commission data on claims for acupuncture performed by a medical practitioner. Participants: A summary of all Medicare acupuncture claims for financial years 1984-85 to 1996-97 and a random sample of patients claiming a Medicare rebate in calendar year 1996. Main outcome measures: Claims for acupuncture by patients' State, sex, age, and the socioeconomic disadvantage index of patients' residences. Results: Between 1984-85 and 1996-97 the number of acupuncture claims increased, but declined as a proportion of total Medicare claims. In 1996, 1.16% of patients claimed for acupuncture, which constituted 0.5% of all Medicare claims. Adjusting for age and socioeconomic disadvantage, women were more likely than men to claim for acupuncture (odds ratio, 1.40; 95% confidence interval, 1.36-1.45). This sex difference is proportionately greater than that for all medical services. Propensity to claim for acupuncture increased with age, peaking at 65-69 years, then declining. Acupuncture claims were more likely in areas just above those assessed as having the greatest social disadvantage. Conclusion: The number of acupuncture claims has increased since 1984. As a proportion of all Medicare claims, acupuncture has remained stable since declining in 1991-92. This suggests that acupuncture is now an established complementary medical practice. Introduction People in the United States,1,2 Canada,3,4 the Netherlands,5,6 the United Kingdom7,8 and Australia9 are increasingly using medicines that are not part of the conventional pharmacopoeia and seeking therapies that are not taught in the conventional medical undergraduate curriculum. A South Australian community study reported that 48.5% of respondents had used such alternative medicines and 20.3% had visited a non-medical practitioner of alternative therapies.10Some general practitioners, as well as non-medical practitioners, provide alternative therapies. Such provision ranges from 16% of general practitioners in Australia,11 Britain12,13 and Canada14 to 30% in New Zealand.15,16 In addition, the proportion of doctors who refer patients to non-medical therapists ranges from 59%-72% in Britain12,13 to 60% in the United States,17 68% in Canada,14,18 80% in New Zealand15,16 and 90% in Holland.6 In Australia one such therapy, acupuncture, is of particular interest in that, although it is used by doctors as part of their normal general practice in many countries, including the UK,13 Canada14 and Holland,6 it is used most extensively by doctors in New Zealand15,16 and Australia.11 Acupuncture is not part of the standard medical curriculum in Australia, but it is recognised as a standard medical therapeutic technique in that it attracts a Medicare rebate (as item 173) when it is performed by a medical practitioner. Other alternative therapies do not attract a rebate or are not so clearly specified. Given this level of government recognition and its use by one in seven Australian general practitioners,11 acupuncture can be considered an addition to general practice in Australia -- a complementary, rather than an alternative, therapy. In this article we examine the characteristics of patients claiming for acupuncture provided by general practitioners, as an extension of our previous report on the characteristics of general practitioners using acupuncture.11 Methods The Health Insurance Commission provided two datasets on the claims submitted by patients involving acupuncture, where those services were provided by medical practitioners. The first dataset was time-series data for the financial years 1984-85 to 1996-97. It includes the number of services and benefits claimed for acupuncture (1984-1990, item 980; 1991-1997, item 173) by State/Territory, age and sex. The second dataset consisted of all Medicare services claimed by patients in the calendar year 1996 -- each case representing an individual patient. We analysed a 1:10 systematic random sample of these data, which included 1 575 173 patients. The data included five variables that measured the frequency of acupuncture claims, frequency of non-acupuncture items, sex, age groupings and postcode. Postcodes were reclassified into 62 categories (consolidated to 12 for presentation) derived from an Australian Bureau of Statistics socioeconomic disadvantage index (SDI).19 SDI groupings were used as proxy measures of socioeconomic status. The 1996 data were analysed using the SAS procedure proc logistic.20 A logistic regression model was fitted to the data to analyse a dichotomous dependent variable (1 = acupuncture service claims, 0 = other service claims). Models were also fitted to four dependent variables representing acupuncture use as quartiles of total service use (ie, 0-25%, 26%-50%, 51%-75%, 76%-100%). Logistic regression odds ratios adjusted for sex, age and SDI were calculated. The University of Tasmania Ethics Committee (Human Experimentation) approved the study. Results Time-series data Between 1984 and 1996, claims for acupuncture rose in all States and Territories except South Australia, where claims began to decrease in 1989, and the Northern Territory, where they began to decrease in 1990. However, in proportion to total Medicare claims, there has been decreased relative demand for acupuncture (Figure). This general Australian decline is echoed in all States and Territories except New South Wales, where demand has fluctuated at a low level. Of particular interest is the order of States and Territories in use of acupuncture throughout the whole time period, with consistently high proportions of claims in Tasmania and South Australia and low levels of claims in the Northern Territory and New South Wales. Separate analyses (not shown) indicate that women make about two-thirds of all claims, except in the Northern Territory, where women make only 55% of claims. When age is examined by sex the picture is more complex. In 1996-97, boys aged 14 years or younger (51.6%; 95% CI, 50.5%-52.7%) were slightly more likely than girls (48.5%; 95% CI, 47.3%-49.5%) to make claims for acupuncture, whereas among older people the pattern was 35% men (95% CI, 34.9%-35.1%) and 65% women (95% CI, 64.9%-65.1%). From 1984 to 1987 claims for both men and women increased with age, peaking at age 55-64 years. However, from 1988 the peak age for women shifted to 45-54 years. There has also been an increase in claims among people 70 years or older, from 7.25% in 1984 to 18% in 1996. 1996 sample data In 1996, acupuncture claims accounted for about 0.5% of all HIC claims for medical services. Of the 1 575 173 patients in our sample, 18 219 (1.16%) claimed for acupuncture. Most patients (16 039; 88.0%) claimed for 10 acupuncture services or fewer, but a small proportion (519; 2.8%) claimed for more than 20 services. High use of acupuncture is only weakly associated with high use of other Medicare services (Pearson's r = 0.07; P < 0.0001). Analyses of the 1996 data (not shown) suggest that, while women (52.7%; 95% CI, 52.6%-52.8%) are more likely than men (47.3%; 95% CI, 47.2%-47.4%) to claim for all types of medical services, their claims for acupuncture are proportionately higher, with 61.7% of those claiming for acupuncture being women (odds ratio [OR], 1.45). These sex differences remain after adjusting for age and SDI (Box). However, acupuncture claims expressed as quartiles (ie, 0-25%, 26%-50%, 51%-75%, 76%-100%) by sex show a different pattern. Sex-based differences tend to decrease as the proportion of acupuncture claims rises. From a logistic regression model (not shown) controlling for age and SDI, no sex-based differences were found for acupuncture claims in the group claiming acupuncture as 76%-100% of all claims (OR, 1.03; 95% CI, 0.91-1.16). As a proportion of all claims, acupuncture claims increased linearly with age (Box), peaking for the 65-69 years age group, then declining. Acupuncture claims tend to be highest in the areas just above the most socioeconomically disadvantaged. Patients in SDI area 2 are 1.7 times (95% CI, 1.58-1.85) more likely to have claimed for acupuncture than those in the area 6 reference group, although the odds ratios for other SDI categories do not exceed 1.3 (Box). Discussion Acupuncture was claimed for by about one in every 100 patients in 1996 and in 1996-97 constituted about 0.5% of all Medicare claims. Although the number of acupuncture claims has increased in the past 13 years, such claims have decreased as a proportion of total Medicare claims. The consistent State/Territory differentials in acupuncture claims are difficult to explain. One possible factor may be ease of access to providers because of the small size of Tasmania and the concentration of the South Australian population in Adelaide. Another may be that these two States have high unemployment, and Medicare-funded acupuncture, unlike medication or physiotherapy, does not require patients to pay for treatment. Acupuncture claims are made more by women than men, and are age-related. The differential between claims made by women and men is greater than the usual disproportion for medical-service claims. This finding appears to lend support to previous research that suggests women are more receptive to alternative techniques.9,10,21 However, this apparent receptiveness varies by age, with boys more likely than girls to receive acupuncture. Further, the peak age for acupuncture claims by women has varied, shifting in 1988 from 55-64 years to 45-54 years. These age variations suggest that the decision to use acupuncture is not solely a function of women's receptiveness to alternative therapies, but is a function of either sex/age-based differences in presenting complaints or doctors' changing willingness to use acupuncture. The increase in claims for acupuncture by middle-aged and elderly patients is also likely to relate to the presenting complaints of patients, or perhaps the lack of success of conventional treatment in alleviating their problems. However, the very weak relationship between high Medicare claims and high acupuncture claims suggests that acupuncture is being used as an alternative to, rather than in conjunction with, other treatments. Whether acupuncture is used after other treatments have failed, as suggested by American2 and Canadian21 research, cannot be ascertained from these HIC data. However, focus groups conducted by one of us (G E) with general practitioner users of acupuncture suggest that it is seen by family doctors as most useful for chronic pain, a symptom more likely to present in middle-aged and elderly patients.22 The higher rate of claims for acupuncture in areas in the lower levels of the SDI scale is contrary to most previous research on alternative therapies,9,10,21 which suggests they are used predominantly by wealthier segments of the community. The fact that these data relate to a Medicare-funded complementary procedure is important in considering this divergence from previous findings. Differences in the rate of acupuncture claims by SDI are not related to the proportion of doctors providing acupuncture in different SDI areas.11 This suggests either that the use of acupuncture is demand-driven rather than supply-driven or that doctors providing acupuncture in low-SDI areas do so to a greater extent through Medicare funding than their colleagues in other SDI areas. However, we recognise that a degree of caution is necessary when interpreting the SDI results, as postcode-based SDI measures may be subject to misclassification error.23 The funding system for Australian healthcare (Medicare and the Health Insurance Commission) provided data which are not available anywhere else in the world. This, coupled with the fact that acupuncture attracts a Medicare rebate if performed by a doctor, enabled us to produce this study, the only national-level study of the characteristics of patients treated with acupuncture. However, the advantages of this dataset are also its disadvantages. The data do not include acupuncture services provided by doctors conducted privately or for insurance companies. Nor do they include the provision of acupuncture by non-medical practitioners. Therefore, these results are not representative of overall acupuncture use or alternative therapies in general. Nevertheless, our results are important at the national level. Acupuncture, a therapy not taught in the standard undergraduate medical curriculum, has been adopted by doctors and used as a complementary therapy throughout Australia. The current Medicare rebate for acupuncture is $18.45, $2.55 less than a standard consultation. Doctors choosing acupuncture are not doing so for monetary reasons. For some doctors it is now an established complementary therapy, apparently chosen for clinical reasons, and a therapy used more frequently with women and elderly patients than with men or young adults and children. Acknowledgements The authors wish to thank the Government Employees Medical Research Fund, which provided funds to conduct the research. References Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs and patterns of use. N Engl J Med 1993; 328: 246-252. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998; 279: 1548-1553. Northcott HC, Bachynsky JA. Concurrent utilization of chiropractic, prescription medicines, nonprescription medicines and alternative health care. Soc Sci Med 1993; 37: 431-435. Blais R, Maiga A, Aboucar A. How different are users and non-users of alternative medicine? Can J Public Health 1997; 88: 159-162. Menges LJ. Regular and alternative medicine: the state of affairs in the Netherlands. Soc Sci Med 1994; 39: 871-873. Visser GJ, Peters L. Alternative medicine and general practitioners in The Netherlands: towards acceptance and integration. Fam Pract 1990; 7: 227-232. Thomas KJ, Carr J, Westlake L, Williams BT. Use of non-orthodox and conventional health care in Great Britain. BMJ 1991; 302: 207-210. Vincent C, Furnham A, Willsmore M. The perceived efficacy of complementary and orthodox medicine in complementary and general practice patients. Health Education Research 1995; 10: 395-405. Lloyd P, Lupton D, Weisner D, Hasleton S. Choosing alternative therapy: an exploratory study of sociodemographic characteristics and motives of patients resident in Sydney. Aust J Public Health 1993; 17: 135-144. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Easthope G, Gill GF, Beilby JJ, Tranter BK. Acupuncture in Australian general practice: practitioner characteristics. Med J Aust 1998; 169: 197-200. Anderson E, Anderson P. General practitioners and alternative medicine. J R Coll Gen Pract 1987; 37: 52-55. Wharton R, Lewith G. Complementary medicine and the general practitioner. BMJ 1986; 292: 1498-1500. Verhoef MJ, Sutherland LR. Alternative medicine and general practitioners. Opinions and behaviour. Can Fam Physician 1995; 41: 1005-1011. Hadley CM. Complementary medicine and the general practitioner: a survey of general practitioners in the Wellington area. N Z Med J 1988; 101: 766-768. Marshall RJ, Gee R, Israel M, et al. The use of alternative therapies by Auckland general practitioners. N Z Med J 1990; 103: 213-215. Borkan J, Neher JO, Anson O, Smoker B. Referrals for alternative therapies. J Fam Pract 1994; 39: 545-550. Goldszmidt M, Levitt C, Duarte-Franco E, Kaczorowiski J. Complementary health services: a survey of general practitioners' views. CMAJ 1995; 153: 29-35. Castles I. Information paper: 1991 census. Socio- economic indexes for areas. Canberra: AGPS, 1994. (Catalogue no. 2912.0.) SAS for Windows [computer program]. Version 6.12. Cary, North Carolina: SAS Institute, 1996. Kelner M, Wellman B. Health care and consumer choice: medical and alternative therapies. Soc Sci Med 1997; 45: 203-212. Astin M, Lawton D, Hirst M. The prevalence of pain in a disabled population. Soc Sci Med 1996; 42: 1457-1464. Hyndman JCG, Holman CDJ, Hockey RL, et al. Misclassification of social disadvantage based on geographical areas: comparisons of postcodes and collectors district analyses. Int J Epidemiol 1995; 24: 165-176. (Received 28 Aug, accepted 11 Dec, 1998) Authors' details School of Sociology and Social Work, University of Tasmania, Hobart, TAS. Gary Easthope, MA, PhD, Associate Professor; Bruce K Tranter, BA, PhD, Lecturer. Division of Community and Rural Health, University of Tasmania, Launceston, TAS. Gerard F Gill, MAE, FRACGP, Clinical Senior Lecturer. Department of General Practice, University of Adelaide, SA. Justin J Beilby, MPH, FRACGP, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Dr G Easthope, School of Sociology and Social Work, University of Tasmania, GPO Box 252-17, Hobart, TAS 7001 Email: Gary. EasthopeATutas.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Acupuncture claims (Medicare Benefits Schedule item 980 from 1984 to 1990; item 173 after 1990) by State and Territory (A), and as a proportion of all claims (B), from financial year 1984-85 to 1996-97. Back to text Characteristics of patients who claimed for acupuncture provided by general practitioners in 1996 (Medicare Benefits Schedule item 173)Number (%) Odds ratio* (95% CI) Sex (n = 18219)Women11233 (61.7%) 1.40 (1.36-1.45) Men6986 (38.3%) 1 Age (n=18219)0-4 years85 (0.5%) 0.08 (0.06-0.10) 5-9 years133 (0.7%) 0.13 (0.11-0.15) 10-14 years263 (1.4%) 0.28 (0.24-0.32) 15-19 years474 (2.6%) 0.49 (0.44-0.54) 20-24 years758 (4.2%) 0.69 (0.63-0.75) 25-34 years2314 (12.7%) 1 35-44 years3438 (18.9%) 1.55 (1.47-1.63) 45-54 years3672 (20.2%) 1.98 (1.88-2.09) 55-64 years3016 (16.6%) 2.36 (2.23-2.49) 65-69 years1447 (7.9%) 2.51 (2.35-2.68) 70-74 years1168 (6.4%) 2.39 (2.23-2.57) 75-79 years818 (4.5%) 2.33 (2.15-2.53) > 80 years633 (3.5%) 1.34 (1.23-1.47) Socioeconomic disadvantage index of claimants (n = 17961) High socioeconomic disadvantage1 300 (1.7%) 1.33 (1.18-1.50) 2 844 (4.7%) 1.71 (1.58-1.85) 3 1047 (5.8%) 1.33 (1.24-1.43) 4 1640 (9.1%) 1.23 (1.16-1.31) 5 2650 (14.8%) 1.27 (1.20-1.34) 6 2283 (12.7%) 1 7 2512 (14.0%) 1.20 (1.13-1.26) 8 2136 (11.9%) 1.20 (1.13-1.27) 9 1734 (9.7%) 1.29 (1.21-1.37) 10 1350 (7.5%) 1.25 (1.17-1.34) 11 864 (4.8%) 1.22 (1.13-1.32) 12 601 (3.3%) 1.34 (1.22-1.46) Low socioeconomic disadvantage * Multiple logistic regression odds ratios adjusted for sex, age and socioeconomic disadvantage index score dummy variables (model chi-squared, 12797.77; df, 25; P < 0.001). Dichotomous dependent variable (1 = acupuncture service claims, 0 = other service claims). CI = confidence interval. Source: Health Insurance Commission 1996. Back to text

Gary Easthope · Gerard F Gill · Justin J Beilby · Bruce K Tranter

Ethics Ethical implications of competition policy in healthcare We need to debate the ethical and philosophical questions underlying the application of market economics to healthcare Paul A Komesaroff MJA 1999; 170: 266-268 Introduction - Assumptions underlying competition policy - Effects of competition policy - Ethical and cultural implications of competition policies in healthcare - Conclusion - References - Authors' details - - More articles on Ethics Introduction The Melbourne Age of 28 July 1998 reported the case of Dr Stephen Vaughan, a medical oncologist, who, after 23 years in public hospitals, resigned, disillusioned and dispirited. According to the Age, Dr Vaughan left medical practice because the value he holds dearest -- caring -- seems to have disappeared. In Dr Vaughan's own words: The personal dimension of care is regarded in the public sector as an optional extra -- but it shouldn't be optional. It is essential. . . . Public hospitals used to be the holder of the values of community and personal caring, irrespective of ability to pay . . . but now they're just another organisation chasing the buck, and if you don't get paid you don't do it.1As the responses in the letters columns seem to attest, this experience of contemporary medicine is common in Australia today. There appears to be a widely felt sense that the opening up of medicine to commercial interests and the promotion of economic competition have undermined fundamental values and seriously threaten patient care. It is widely felt, too, that these issues have been substantially neglected in the public debates, which have focused almost exclusively on technical issues of financing at the expense of ethical and cultural questions.2 I shall argue that the social policy which promotes economic competition as a major technique for regulating the healthcare industry raises a wide range of issues about the organisation and dynamics of healthcare and is likely to lead to a variety of outcomes that are not beneficial. Before committing ourselves irrevocably to such a policy we need to consider not just the economic variables, narrowly defined, but also the underlying ethical and philosophical questions. Assumptions underlying competition policy Soon after taking office, in May 1996, the Minister for Health, Dr Michael Wooldridge, declared the government's commitment to promoting competition in the healthcare sector: One fundamental of micro-economic reform has been the application of competition principles to industry -- including those where public sector funding and provision has been significant, as it is in the health sector. These principles are based upon an approach [in] which decisions about the use of resources are made in the light of independent bids for the provision of goods or services made by players who are not in any way in collusion.3An increasing emphasis on the role of the market in regulating decision making is at the centre of the national competition policy for healthcare in Australia (Box). Its advocates argue that enhanced conditions of competition among doctors, hospitals and insurers should be supported for two reasons: because they are necessary to contain healthcare costs and because they will provoke a shift in the healthcare power balance from providers -- that is, doctors -- to consumers -- that is, patients. Many of the assumptions underlying such a perspective, however, depend on a view of human action and relationships that can be contested on both philosophical and factual grounds. For example, it is assumed that consumers always act out of self-interest, that they use their own money to buy all goods and services, and that they seek the best price quantity/quality combination to maximise total utility. Similarly, it is assumed that providers are also primarily concerned with their own interests, adapt their prices and throughput in the light of consumers' purchasing, act to maximise profits by increasing market share at acceptable prices, and always seek to use labour and resources sparingly. All of these assumptions are mistaken, at least with respect to medicine. Although economic constraints of some kind are obviously unavoidable, it does not follow that these must be derived from the market. As is widely acknowledged, the healthcare market is not a perfect one.9 Individual patients by and large do not behave like typical consumers. Ordinary people cannot always understand the complex healthcare field, their needs are immediate, and decisions need to be taken under conditions of duress. In addition, patients become dependent on doctors with whom they have established ongoing relationships of trust and who in turn are sincerely committed to their patients' interests. Effects of competition policy Where competition policies have been introduced elsewhere it is not clear that they have produced beneficial effects. Indeed, economic competition in healthcare may raise costs rather than reducing them.3,10 For example, in California, where these models have been heavily promoted, healthcare-spending growth is faster than in any other American state and costs are now the second highest in the country. Likewise, in New Zealand, where similar policies were introduced over the past six years, it is claimed that distortions created by the economic incentives have led to overservicing in some areas and underservicing in others.11-13Similarly, the effect of competition policies on consumer choice has been mixed. Limitation of the sovereignty of physicians does not necessarily mean increased possibilities for patients. On the contrary, to the extent that market-based incentives tend to operate against the most needy and vulnerable members of the community, the indigent and socially disadvantaged populations are likely to be worse off under a more competitive system. In the US, where it is commonplace for healthcare organisations to seek openly to maximise their profits by restricting medical care in individual cases, this appears commonly to be the case.3,14 In Australia, the introduction of casemix funding has openly discouraged admissions for social or compassionate reasons by attributing low weights in these categories, and there is evidence that specific social groups may be particularly disadvantaged.15 Ethical and cultural implications of competition policies in healthcare The promotion of market-based incentives and discentives as the main regulating mechanism for the healthcare system affects not just the "economic variables" -- it also influences the quality of healthcare in general and the experiences of patients and doctors that emerge from it. Indeed, competition policies explicitly seek to challenge many of the traditional norms underlying medical practice, on the assumption that these are simply devices for protecting the financial interests and power of physicians.10As both doctors and patients have always recognised, however, the medical relationship cannot be understood purely as a commercial relationship. Patients come to doctors because they are experiencing pain, illness or fear. They offer access to their bodies and to the intimate recesses of their personal lives. They grant wide discretion and decision-making power to doctors, on the understanding that doctors will exercise their judgement in a disinterested and compassionate manner. It is mutually agreed that the power of doctors is subject to rigorous ethical constraints arising from the long tradition of medicine, which have been upheld by the professional organisations for hundreds of years. These constraints, which constitute a complex, self-generated system of professional norms, limit the nature of personal relations between doctors and patients, the use and dissemination of information, licensing and credentialling of practitioners, and specific commercial practices such as fee splitting, advertising, self-referral, and ownership of pharmacies and hospitals by physicians. They primarily reflect altruistic concerns of doctors to separate personal and financial considerations from the paramount professional goal of doing what is best for their patients, even if, undeniably, they also have the effect of protecting doctors' financial interests. They do not prohibit competition, but rather channel it into non-economic forms, such as competition for reputation, recognition and status, and social influence. Emphasising economic values undermines the role and power of ethical values.16 This fundamental shift may in the longer run prove deeply significant for society as a whole, for it may lead to changes in the structure and dynamics of the clinical process itself. A crucial aspect of the medical encounter is that it is not purely "instrumental" in character. It does not merely subserve technical functions, the solution of problems in biochemistry or physiology through the application of scientific modes of thought and analysis. It is also involved in setting goals, in identifying and scrutinising meanings, and in establishing the frameworks within which the technical problems are identified and given a value. These latter functions are "non-instrumental" in character, and become possible because of the peculiar nature of the contact between doctor and patient: its intimacy and openness, its reliance on vulnerability and trust, the moment of sanctuary it offers with respect to the utilitarian relationships of everyday life. It is through the contact that the doctor is granted with the lifeworld of the patient that the healing process becomes possible. This contact, which occurs through a variety of mechanisms, including language and touch, stands at the irreducible core of clinical medicine. It is an unavoidable consequence of the introduction of the unrestrained operation of market forces into healthcare that economic values penetrate to the heart of the medical relationship. Indeed, it is precisely the rationale of the policy that financial imperatives take over as the motivating principle of all medical decision making. To open up the clinical relationship to such forces, to subject it to criteria that are purely calculable and quantitative, risks undermining the dynamic structure on which the entire medical enterprise rests. The physician becomes the agent of the hospital or the system rather than of the patient. His or her primary obligation to act on behalf of the patient is displaced in favour of conformity to a complex system of economic incentives and disincentives. The scope for disinterested, compassionate care is greatly contracted.17 The opportunities to respond to individual needs, to the specific details of the predicament of a particular patient, are severely contracted in the face of the overwhelming power of economic imperatives.18 Health-financing policies cannot be understood as exclusively technical, or "value free", mechanisms for regulating the healthcare system. Rather, they must be interpreted and evaluated in accordance with philosophical and ethical criteria and in relation to their social and cultural consequences.19 We need to ask not merely Is this a way to balance the books? but also Is this the kind of healthcare system we want to have? If this simple test is adopted it becomes immediately apparent that a reliance on economic incentives to regulate the quality and distribution of healthcare resources is, through its effect on the conduct of doctors and the outcomes for patients, very likely to lead to consequences widely considered unacceptable. Conclusion Clearly, action to limit healthcare costs is widely supported in the community. Among the possible strategies for achieving this end, an enhanced emphasis on economic incentives and disincentives has gained popularity around the world. Although the stated aim of this policy is to reduce healthcare costs and increase consumer sovereignty, whether it will achieve these objectives is open to question. The employment of economic competition as a key device in the regulation of the healthcare system, however, is more than a mere technical solution to a fiscal problem. It is an intervention that raises issues at medicine's philosophical core. One of the major objectives of competition policies is to challenge the traditional system of norms that guide the behaviour of physicians; the implications of this are potentially far-reaching. The possibility that the introduction of economic imperatives at the heart of the medical endeavour may compromise it in a fundamental way also needs to be considered. The globalisation of the economy -- in the dual sense of the elimination of national boundaries and the universalisation of economic values -- has the capacity to profoundly transform the nature of the entire domain of healthcare. To be sure, it may usher in lower prices for some services and enhanced availability of others. However, the cost of these gains may be very high, for it may also lead to the corruption of some of the central values of medicine, and to a contraction of the sphere for individual action in favour of the uncompromising demands of the ever-expanding system. This scenario -- and that depicted by Dr Vaughan -- may, of course, be too bleak. Perhaps the traditional values of medicine will prove to be sufficiently resilient to survive under the changed social and economic conditions, as indeed they have over the millennia. Naturally, it is to be hoped that this will be the case. Nonetheless, it is essential that proposed new directions in healthcare policy are subjected to rigorous scrutiny in relation not merely to narrowly conceived fiscal criteria but also to cultural and ethical ones in open, public debate. References Toy M-A, Birnbauer B. This man has been a cancer specialist for 23 years. Last week he quit. Why? The Age (Melbourne) 1998; 28 July: 1. Lown B. Physicians need to fight the business model of medicine. Hippocrates 1998; 12: 25-28. Wooldridge M. Opening. In: AMA Summit proceedings. Competition in health: a brave new world? Canberra: Australian Medical Association, 1996; 2-9. Glaser WA. The competition vogue and its outcomes. Lancet 1993; 341: 805-812. Enthoven AC, Kronick R. Consumer-choice health plan for the 1990s. N Engl J Med 1989; 320: 29-37, 94-101. Kuttner R. Physician-operated networks and the new antitrust laws. N Engl J Med 1997; 336: 386-391. Changra J, Kakabsadse A. Privatisation and the National Health Service. Aldershot: Gower, 1985. Fels A. The ACCC approach to health. In: AMA Summit proceedings. Competition in health: a brave new world? Canberra: Australian Medical Association, 1996; 14-20. Reinhardt UE. Accountable health care: is it compatible with social solidarity? London: Office of Health Economics, 1997. Robinson JL, Luft HS. Competition and the cost of hospital care. JAMA 1987; 257: 3241-3245. Pezaro D. The New Zealand view. In: AMA Summit proceedings. Competition in health: a brave new world? Canberra: Australian Medical Association, 1996; 9-13. Hemenwon D, Killen A, Cashman SB, et al. Physicians' responses to financial incentives: evidence from a for-profit ambulatory care center. N Engl J Med 1990; 322: 1059-1063. Hillman A, Pauly MV, Kerstein JJ. How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organisations. N Engl J Med 1989; 321: 86-92. Brown ER, Dallek G. Changing health care in Los Angeles. In: Ginzberg E, Berliner HS, Oston M, Brown ER, editors. Changing US health care: a study of four metropolitan areas. Boulder: Westview, 1993. Ruben AR, Fisher DA. The casemix system of hospital funding can further disadvantage Aboriginal children. Med J Aust 1998; 169 Suppl Oct 19; S6-S10. Pellegrino ED. Ethics. JAMA 1994; 271: 1668-1670. Agich GJ, Begley CE. Some problems with pro-competition reforms. Soc Sci Med 1985; 21: 623-630. Weber M. Science as a vocation. In: Gerth HH, Mills CW, editors. From Max Weber: essays in sociology. London: Routledge and Kegan Paul, 1964; 129-158. Charlesworth M. The new ideology of health care: ethical issues. In: Halasz G, on behalf of the Psychiatrists Working Group, editors. She won't be right, mate: the impact of managed care in Australian psychiatry and the Australian community. Melbourne: Psychiatrists Working Group, 1997; 104-110. A version of this article was given as an oral presentation at the Australian Medical Association conference Competition in health, Canberra, 31 July 1998. Authors' details Department of Medicine, Monash University, Melbourne, VIC. Paul A Komesaroff, PhD, FRACP, Associate Professor, and Director, Eleanor Shaw Centre for the Study of Medicine, Society and Law, Baker Medical Research Institute, Melbourne. Reprints will not be available from the author. Correspondence: Dr P A Komesaroff, Director, Eleanor Shaw Centre for the Study of Medicine, Society and Law, Baker Medical Research Institute, PO Box 6492, St Kilda Central, VIC 8008. Email: Paul. KomesaroffATbaker.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> What is competition policy? Competition policy is an economic and political strategy for ensuring that market forces operate as the principal device for the regulation of economic relations. Several approaches reflect the range of economic theories and philosophical perspectives represented.4 In the United States, antitrust laws are used to break up arrangements such as fee schedules by medical associations, corporations among hospitals, collective bargaining between providers and insurance carriers and payer reimbursement. More recently, managed care has emerged as a major approach to cost containment.5,6 In the United Kingdom under the Thatcher Government, certain services were contracted out to private firms and hospital and general practitioners were granted a substantial degree of financial autonomy.7 In Australia, a National Competition Policy was introduced in 1995 with bilateral support, establishing competition and cost considerations as the guiding principle of public policy at every level of government. This policy is enforced through a framework of law -- including the Trade Practices Act 1973, the Competition Policy Reform Act 1995 and the Prices Surveillance Act 1983 -- and two key regulatory bodies, the Australian Competition and Consumer Commission and the National Competition Council.8 These regulatory bodies have very wide powers to oppose "anti-competitive conduct and unfair market practices" of all kinds, and to regulate "mergers or acquisitions of companies, product safety/liability and third party access to facilities of national significance". Back to text

Paul A Komesaroff