Volume 192 Issue 9

Patients need to make an informed choice about their pathology referrals In February 2010, despite representations from the Royal College of Pathologists of Australasia (RCPA) and the Royal Australian College of General Practitioners (conveyed via letters, meetings and discussions), the federal government introduced legislation into Parliament to require all pathology request forms to be marked with the advice to patients that they may be taken to any pathology provider.1 Pathology services underpin modern health care, playing a role in 70% of diagnoses and medical decisions.2 The key concern of health professionals is that the “non directed” pathology referral will put patient safety at risk and undermine the quality of information that pathologists provide to patient care. The proposed legislation arose from an interdepartmental review of pathology funding led by the Australian Department of Finance and Deregulation and is touted as creating patient choice.3 However, from the health professional’s perspective, the initiative may seem, at best, disingenuous. Patients have always had the right to take part in choosing their pathology provider — as they do for other medical specialist referrals. Shared decision making between doctor and patient is the strength of the medical specialist referral system, and is of particular importance in making choices about pathology (the “invisible” medical specialty). Amending the request form with a clause advising patients that it may be taken to any pathology provider encourages patients to make the decision on their own, after they have left their doctor’s surgery — thus making this a “patient choice” initiative that threatens fully informed choice. Patients may infer from this government directive that it does not matter which pathology provider they use — that they are all the same. In fact, this is not the case. Although all pathology providers are required to meet a national standard of accreditation, they differ in the range of expertise of their pathologists and laboratory teams, their test catalogue and technologies, the content of reports, their second-opinion networks, their access to pathologists for advice, their turnaround times and notification of urgent results, and their after-hours services. Little of this variability may be apparent to patients, who may instead make their “choice” on the convenience of sample collection and price alone, without due regard to the nature of the pathology consultation their doctor sought or whether the important information will be effectively communicated to their doctor. Patients may choose to shuttle between various pathology providers without understanding the effect this journey may have on the type and usefulness of information provided by pathology testing. For many diseases, a unique diagnostic opportunity arises from testing being carried out in one laboratory over the course of a patient’s acute illness. Pathologists can integrate the findings of a range of tests over time to make a diagnosis and can identify disease progression, remission and recurrence earlier, and with more certainty, from a complete and continuous pathology record. Patients with chronic diseases may understand the importance of serial pathology testing, but may not realise that the tests performed and their reference ranges may vary between laboratories, to the extent that the use of multiple pathology practices could compromise their doctor’s efforts to monitor results and could even affect their treatment. Even laboratories that use the same reference ranges may use their own cumulative or graphical reports of test results to highlight changes in the control of common diseases such as diabetes and cancer and in warfarin therapy. Thus, significant changes in a patient’s disease status may not be recognised if they are presented by a new pathology provider independently of previous data gathered on the patient. Lastly, patients may not understand the effect that their independent choices about pathology providers may have on the communication and traceability of their results. The information required for critical decisions may be delayed or lost because the pathology practice cannot deliver reports to an unknown doctor and the doctor cannot pursue them because he or she does not know which practice the patient chose to attend. A large medical indemnity organisation has indicated that it will need to provide risk management advice to its members should this measure be implemented (David Nathan, Chief Executive Officer, Avant Mutual Group Limited, in a letter dated 3 November 2009 referring to an RCPA letter sent to medical indemnity insurers on 17 September 2009 to acquaint them with this measure). Is this good health policy? Can it be good if it cuts across pre-existing good policy on quality, safety and connectivity (ie, delivery of medical information by information technology systems). The federal government seems intent on proceeding with this legislation, despite the establishment of a Senate inquiry into the risks it poses to patient safety.4 Why is this? Why is the government seeking to interfere in and weaken the doctor’s role in advising patients about their health care? If this is about patient choice, then surely patients would universally choose to be safe? So, if it is not about patient choice, what is it about? By portraying pathology services to the Australian public as being all the same, with no distinction made between the levels of service or expertise offered by different providers, the Department of Finance and Deregulation would be sending a message that pathology is a commodity, to be bought at the lowest price. This premise could be used to justify fee cuts and tendering, both of which are on the federal government’s radar.5 All Australians (including patients and doctors) need to be aware of the risk to patient care once the case has been made that pathology is a commodity rather than a medical service. This risk is not merely theoretical. In Ireland, after a recent government-led tender, all Pap smears from Irish women are now to be reported by a pathology service in the United States — effectively putting an end to training (and the destruction of competency) of Irish pathologists in this area of pathology.6 In New Zealand over the past decade, tendering of pathology in each of the 21 district health boards has disrupted not only patient care but also the pathology workforce.7 There has already been significant government disinvestment in Australian pathology over the past 5 years, with the proportion of the Medicare dollar spent on pathology falling significantly despite a dramatic rise in test numbers over that period (Ed Wilson, Principal, EW Consulting P/L, personal communication). A further government review of pathology funding is underway.5 It is aimed at saving more money and will bring us closer to the line beyond which funding is no longer sufficient to allow pathology practices to maintain the standard expected by Australian doctors and their patients. In recent years, this line has probably already been crossed in Canada, where chronic underfunding has been identified as a major cause of the widespread failure of diagnosis of breast cancer, with resultant government inquiries being conducted.8 The proposed changes to legislation cannot be justified on the spurious grounds that pathology is a commodity and that patients are being offered “choice”, when in fact the choice already existed. If the federal government’s agenda is to reduce funding for pathology services, it needs to take responsibility for its decision and the consequences of that decision for patient care.

Beverley J Rowbotham MD, FRACP, FRCPA

Doctors can best contribute to environmental sustainability by their example and by working actively to change social norms McDermott’s article in this issue of the Journal (The carbon footprints of obesity, chronic disease and population growth: four things doctors can do)1 calls doctors to arms, in the tradition of the famed 19th-century German pathologist Rudolf Virchow and today’s Medical Association for the Prevention of War, to contribute to a better world. Its writer draws attention to profound issues and is to be congratulated. However, her recommendations are not so straightforward. Taken neat, the cure might do more harm than good. Consider obesity. Indeed, a recent article found that an obese population requires substantially more food energy than one with a normal body mass index distribution,2 although it is unclear whether the authors fully considered the shorter life expectancy and lower class-related reduction in other aspects of the ecological footprint of the obese. Elite sportspeople and military recruits also consume disproportionate amounts of food and other resources, but these harder targets were not mentioned. Singling out the obese seems simplistic and discriminatory.3 McDermott also advocates enhanced rights-based family planning, in rich and poor nations, as a means to reduce climate change. She discusses a recent report that found a high climate return for a low cost (that of funding family planning).4 As she mentions,1 the methods used in this thesis can be challenged, as it is obvious that growth in size of wealthy populations fuels far more climate change than does growth in size of poor populations, a distinction that is not clearly made. Criticising the poor for their population growth rate risks becoming another form of victim blaming. However, in the long run, slower population growth everywhere (especially in countries like Australia and the United States) will slow greenhouse gas accumulation. It will also enhance population health in low-income countries. McDermott also correctly advocates social, health and rights-based strategies to complement the largely technical and economic approach to climate change that is now dominant.5 It is easy to list actions that will improve global public health. However, compilers of lists need not only to prioritise their lists’ components, but also to describe how we can realise them. It is true that doctors are powerful role models, and the recent tentative steps by doctors and medical associations to recognise and address the health and other risks of climate change6 are important. However, the virtual absence of health (and the global population) as agenda items for the recent climate change talks in Copenhagen underlines how far there is to go. It is also easy to call for “whole-of-government” approaches, whether to slow climate change, fix the obesogenic environment or to enhance equity. Easy to say, hard to achieve. A well known economic principle is the law of diminishing returns. A second ice-cream is not as tasty as the first. Less well known is the Matthew effect, or the law of increasing returns.7 This principle is a powerful impediment, not only to whole-of-government reforms, but to the transition to sustainability more broadly. Simply put, this principle describes how groups with influence are able to rig public opinion and legislate to benefit powerful minorities rather than the public good.8 The 18th-century philosopher Adam Smith warned against monopolies. The benefits to society and public health, including life expectancy, from reduced inequality are perennially rediscovered.9 Yet progress on reforming coal-fired electricity generation remains stalled both here and in Washington. Advancement of public goods such as public health and climate stability is thwarted by well funded and well organised lobbyists, who far outnumber public-good lobbyists.10 This illustrates an embedded Matthew effect, long operant in the US, and one about which Australia should not be complacent. Our long life expectancy might not always remain so.11 What is it, in this country, that prevents more extreme ideologies from taking root? The answer, in part, lies in our cultural norms and practices, such as our ostensibly “fair go” society, and in a reasonably free press. McDermott’s article1 and its receptive readers help counter the advantages of the powerful. On reflection, it is not hard to see how the attitudes and norms of readers sympathetic to this analysis evolved. We all received a publicly subsidised education. Some of us descend from people who struggled for the opportunities and wealth we may now take for granted. Before our birth, large social movements worked intensely for a fairer world, using organised tactics that reduced the advantages, often hereditary, of those more powerful. Some of this resolution was forged in the trauma of World War II and the preceding Great Depression, helping to deliver the National Health Service in the United Kingdom and diluted copies of it elsewhere. Then, largely in the same English-speaking world, a less vigilant generation was seduced by the “fool’s gold” of neoliberalism, the conceit that marketism would deliver more public goods than would regulation.12 This false remedy has not only generated a decline in equity, but now threatens the whole of civilization.11 What can doctors do? Reflect and act, not just on the four themes proposed by McDermott, but on four hundred more. They can green their clinics, reduce their own footprint and join like-minded groups. There is no single recipe, but the principles of environmental sustainability, justice and commonsense are integral, as are courage and collaboration. Such action may work as a social vaccine against despair. Doctors, with other groups, may long postpone the world’s admission to intensive care.

Colin D Butler BMed, MSc, PhD

Decisions regarding the use of triple therapy should take into account the balance between thromboembolism and bleeding risk in individual patients The combined use of warfarin and dual antiplatelet therapy (aspirin plus clopidogrel) — so-called triple therapy — is a challenging management problem in patients with a coronary stent who also have an indication for oral anticoagulation. One of the most common clinical scenarios is a patient with atrial fibrillation (AF) who undergoes percutaneous coronary intervention with stenting. Guidelines for antithrombotic therapy recommend that patients with AF who are at high risk of stroke (ie, prior history of stroke or more than one of: age ≥ 75 years, hypertension, diabetes, and congestive cardiac failure) receive warfarin;1 and guidelines for percutaneous coronary intervention management recommend dual antiplatelet therapy in all stent patients to prevent stent thrombosis.2 Both warfarin and clopidogrel increase the risk of bleeding in patients treated with aspirin, and combining all three drugs can be expected to further increase bleeding risk. However, the efficacy and safety of triple therapy have not been evaluated in randomised controlled trials. What is the evidence concerning the efficacy of anticoagulation or antiplatelet therapy in patients with AF who have recently received a coronary artery stent? In patients with AF who are at risk of stroke, warfarin compared with placebo or no treatment reduces the risk of stroke by about two-thirds, whereas aspirin reduces the risk by about one-fifth.3 Adding clopidogrel to aspirin improves the effectiveness of antiplatelet therapy for stroke prevention,4 but warfarin is substantially more effective than dual antiplatelet therapy.5 In patients with a recent coronary artery stent, dual antiplatelet therapy compared with the combination of aspirin and warfarin reduces death or myocardial infarction by half.6 Premature discontinuation of clopidogrel (less than 3 months of treatment for sirolimus-eluting stents; less than 6 months for paclitaxel-eluting stents) is the single most important risk factor for stent thrombosis.7 The efficacy and safety of triple therapy have been examined in multiple observational studies. Meta-analysis of 10 observational studies involving 1349 patients with AF who received triple therapy after stent insertion revealed a weighted mean incidence of major bleeding at 30 days of 2.2% (95% CI, 0.7%–3.7%).8 Increasing the duration of triple therapy to longer than 6 months doubles the risk of major bleeding compared with 1 month of treatment.9 The guidelines recommend at least 4 weeks of dual antiplatelet therapy for patients who receive a bare metal stent and at least 1 year for those who receive a drug-eluting stent.2 What is the optimum antithrombotic management of patients with AF who undergo coronary stent insertion? Decisions regarding the use of triple therapy should take into account the balance between thromboembolism and bleeding risk in individual patients. Dual antiplatelet therapy alone is likely to be adequate for stent patients with AF if they are at low or moderate risk of stroke (CHADS2 stroke risk score [congestive heart failure, hypertension, age ≥ 75 years, diabetes, 1 point each; previous stroke or transient ischaemic attack, 2 points10], 0–1), or if they are at high risk of stroke (CHADS2 stroke risk score, > 1) and deemed to be at unacceptably high risk of bleeding with triple therapy. The most important risk factors for bleeding are older age (eg, > 75 years), severe renal dysfunction (eg, creatinine clearance < 30 mL/min), recent gastrointestinal bleeding (eg, within 6 months), previous stroke, and uncontrolled hypertension (eg, systolic blood pressure > 160 mmHg, diastolic blood pressure > 110 mmHg).11 All other patients with AF who are at high risk of stroke (CHADS2 stroke risk score, > 1) and have recently undergone coronary artery stenting should probably receive warfarin in addition to dual antiplatelet therapy (Box).8 Cardiologists and primary care physicians should communicate closely to optimise antithrombotic therapy and minimise the risk of bleeding in patients who may be candidates for triple therapy. Firstly, the duration of exposure to triple therapy should be limited where possible by selecting a bare metal stent, which requires a shorter duration of antiplatelet therapy than a drug-eluting stent.2 Secondly, aspirin should be used at the lowest proven effective dose of 50–100 mg/day to minimise the risk of gastrointestinal bleeding.12 Thirdly, in patients at high risk of gastrointestinal bleeding, consideration should be given to the use of acid-suppressive therapy, either with a histamine H2-receptor antagonist (eg, ranitidine) or a proton-pump inhibitor.13 Retrospective analyses of administrative databases have suggested that the concomitant use of a proton-pump inhibitor (particularly omeprazole) reduced the efficacy of clopidogrel,14,15 but subsequent analyses of data from randomised controlled trials indicated no loss of benefit of clopidogrel when the two were used in combination.16 If a proton-pump inhibitor is used, it may be reasonable to avoid the use of omeprazole. Finally, warfarin therapy should, ideally, be monitored by an expert anticoagulation clinic to optimise the quality of international normalised ratio (INR) control (target INR, 2–3).11 What are the unresolved issues? Our recommendations for the use of triple antithrombotic therapy in patients with AF and a stent are based on observational studies8 and extrapolations of evidence from randomised controlled trials of antithrombotic therapy for prevention of stent thrombosis and thromboembolism in patients with AF. Dedicated randomised studies are urgently needed to obtain more reliable estimates of the risks and benefits of triple antithrombotic therapy in patients with a coronary artery stent who have AF, as well as in stent patients with other indications for warfarin therapy, such as mechanical heart valves or recent venous thromboembolism. Treatment decision algorithm for patients with atrial fibrillation and a coronary artery stent8 * CHADS2 stroke risk score (congestive heart failure, hypertension, age ≥ 75 years, diabetes, 1 point each; previous stroke or transient ischaemic attack, 2 points).10

Jeremy S Paikin MD · Shamir R Mehta MD, MSc, FRCPC · John W Eikelboom MB BS, MSc

Objective: To identify the number of Australian clinical practice guidelines, and their key characteristics.Design, setting and participants: Clinical practice guidelines that were produced or reviewed between 2003 and 2007 for use in Australia at a national or state level were identified by approaching health-related organisations and searching websites. Their characteristics were abstracted from the published guidelines and publicly accessible accompanying material.Main outcome measures: Number of clinical practice guidelines, key health areas, documentation of evidence search and appraisal processes, numbers and types of guideline producers and funders, presence of competing interest statements.Results: 313 clinical practice guidelines were identified, of which 91 (29%) were evidence-documented, either in the guideline itself or in an accessible accompanying document. Over 80 guideline producers were identified. Federal or state government agencies produced or contributed funding to 53% of the guidelines (167/313); 28% of the guidelines supported by government agencies (46/167) were categorised as evidence-documented. A review date was specified in 52% of evidence-documented guidelines (47/91), but a third of these had passed the review date at the time of our study and no updated guidelines were found. Areas with a large burden of disease did not necessarily receive government support for guideline development. Most guidelines (246/313; 79%) made no mention of possible competing interests of members of the guideline development group.Conclusions: A more coordinated approach to identifying national priorities for developing and updating clinical practice guidelines may produce better returns on investment in Australian guidelines. In addition, more transparency in documenting the guideline development process, including details on competing interests, is needed.

Heather A Buchan MB ChB, MSc, FAFPHM · Kay C Currie BA, GradDipAppPsych, MPH · Emma J Lourey BA(Hons) · Geraint R Duggan BA(Hons), RN, MBioethics

Objective: To evaluate the assessment and treatment outcomes of a prison hepatitis service.Design and setting: A retrospective, observational cohort study of prison inmates who attended hepatitis clinics from 1996 to 2005 at correctional centres in New South Wales.Patients: Inmates who attended the clinics, including a nested case–control series of patients who received antiviral treatment and age- and sex-matched patients who did not receive treatment.Main outcome measures: Demographic and clinical characteristics of patients who attended the service; correlates of selection for antiviral treatment; and clinical and virological outcomes of treatment.Results: Of the 1043 inmates who attended the clinics, 851 were men (82%) and 994 (95%) were referred for HCV infection; the mean age for this group was 33 years (range, 18–74 years). In the case–control series (185 treated and 186 untreated patients), selection for treatment was not biased by culturally and linguistically diverse background, current methadone treatment or psychiatric status. In the treated group, 76 of 138 genotyped patients had a genotype that is predictive of favourable treatment response, and a small minority of those with available liver biopsy results had established cirrhosis (7/119 patients). Of treated patients for whom complete follow-up data were available, 55% achieved sustained virological response and 100% adhered to therapy. In addition, treatment episodes were not especially complicated.Conclusion: Although the prison population has high rates of injecting drug use and poor mental health, imprisonment offers an opportunity for assessment and treatment of chronic HCV infection.

Leng Boonwaat RN, MPH · Paul S Haber BSc, MD, FRACP · Michael H Levy MB BS, MPH, FAFPHM · Andrew R Lloyd MB BS, MD, FRACP

Objective: To compare rates of visits to a general practitioner between users and non-users of mental health services (MHS).Design, participants and setting: Population-based retrospective cohort study of 204 727 users and 294 076 matched non-users of MHS in Western Australia from 1 January 1990 to 30 June 2006, based on linked records of the use of MHS, hospital admissions, Medicare claims for GP and specialist services, electoral roll registration and deaths.Main outcome measures: Adjusted rate ratios (ARRs) for the number of visits to GPs by users of MHS relative to non-users, and for different categories of mental disorders.Results: Relative to non-users of MHS, the ARR of visits to GPs by users of MHS was 1.622 (95% CI, 1.613–1.631) overall, and was elevated in each separate category of mental illness. ARRs were highest for alcohol/drug disorders, schizophrenia and affective psychoses (2.404, 1.834 and 1.798, respectively). The results were not changed by location (metropolitan, rural or remote addresses). However, the 4% of MHS users with no fixed address had a very low ARR of visits to GPs (0.058; 95% CI, 0.057–0.060).Conclusions: Users of MHS visit GPs substantially more often than non-users, with the exception of those with no fixed address who seldom see a GP at all.

Qun Mai MB BS, MPH · C D’Arcy J Holman MPH, PhD, FAFPHM · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · Jonathan D Emery MB BCh, DPhil, FRACGP · Louise M Stewart BSc(Hons), GradDipPublicHealth

“Funded nationally, run locally” The Rudd Labor government came to power in November 2007 promising to enact “the single biggest health reform in a quarter of a century”.1 The political rhetoric became reality in March 2010 with the release of the reform plan, A national health and hospitals network for Australia’s future,2 and the essence of the reform is evident from its catchcry, “funded nationally, run locally”. The plan outlines a scheme for funding the new order that supposedly will banish the blame game that has debilitated health care delivery in this country for far too long. The kernel of the reform is an ill-defined national health and hospitals network, but, overall, the reform package consists of three areas for reform: funding, structural changes and national standards. As to the first of this triumvirate of reforms, the federal government will fund 60% of the efficient price of services provided to public hospital patients. The states will inherit the remaining 40% of the cost. This financial support will be funded through reallocation of revenue raised by the prevailing Goods and Services Tax. In addition, there is also a commitment to provide funding support for research and teaching. Details of the structural proposal of local hospital networks are vague, but will consist of networks of public hospitals and other health services aggregated according to geographic or functional links. A board made up of local professionals, including doctors, nurses and other health professionals, will govern this cluster. As a major driver of quality and performance, the federal government will introduce a code of standards, which will have both negative and positive rewards for compliance. Since its release, the proposal for national health and hospital reform has been extensively dissected and debated in the mainstream media, including in a debate at the National Press Club between the Prime Minister Kevin Rudd and the Leader of the Opposition Tony Abbott, which screened live on 23 March 2010, and was adjudicated by the notorious “worm” (which uses audience opinions to indicate which leader’s argument is the most appealing). To join in this community-wide debate, the Journal has sought the views of six prominent medical and health leaders, which were published as rapid-online articles in March in the eMJA, but are now also published in this issue of the Journal. All commentators raised issues and uncertainties with the reform package. Overall, the verdict was that the plan lacked comprehensive details, but it is time to seek the opinions of the profession at large — the vox populi of doctors! In a lecture to Harvard medical students in the 1920s, Francis Peabody, the famed Bostonian physician, coined a phrase that captured the essence of health care: “the secret of the care of the patient is in caring for the patient”.3 The Rudd reform package is more about the structural processes and mechanisms of health care delivery than caring for the patient. We await the verdicts of our readers.

Martin B Van Der Weyden MD, FRACP, FRCPA

It is the long term that matters — not a quick fix Kevin Rudd’s election commitment in November 2007 to take over the funding of public hospitals and fix them has led to a bold and courageous plan,1 unveiled after a 15-month review by the National Health and Hospitals Reform Commission (NHHRC) and further extensive consultations. Some pillory the delay, but with such a complex system and so much at stake, caution is admirable. The real questions are whether the solution offered on 3 March 2010 for public hospitals1 will work, and what problems will it solve? Further debate is urgently needed. The NHHRC report2 had worthy features and intentions, but fundamental flaws as a basis for reform. Public hospitals must be seen in the wide context of health care, not in isolation. No doubt further statements on primary care and prevention are to come, but the 3 March statement only covers hospital reform. Many unanswered questions remain. What were the serious flaws in the NHHRC report and do they matter? First, the report saw health care as a series of silos with separate control, regulatory processes and funding streams covering public hospitals, primary care, aged care, mental health, health workforce education, preventive care, research, quality and safety oversight, and so on, when the imperative is to bring all these to effectively overlap and intertwine at the local level. This is what the community needs. Second, it saw control of public hospitals, as developed over the past 15 years, as a matter of external numerical control of “casemix” numbers and budgets, and regulation based on waiting lists and waiting times in emergency services. The disasters in Bundaberg3 and at the Royal North Shore Hospital,4 and even in the trauma unit at the Alfred Hospital in Melbourne,5 all occurred in hospitals performing well on numbers and budgets! Third, the report paid little attention to clinical governance. Good and safe care, research and development, so the best care is offered to all, and good education of health professionals (the investment for future care) depend on professionals taking pride in the quality of services offered. This is a powerful resource if wisely used. Clinical governance is needed to secure safety and quality when difficult judgements have to be made every day in caring for acutely ill patients. Some mistakes are inevitable. Involvement of professionals with management is vital. External agencies based in Canberra, or even state departments, cannot deliver this. Finally, its consideration of aged care did not focus on the critical community sector. The escalating costs of an ageing population will create huge problems, as shown in the Treasury’s 2010 Intergenerational report.6 However, care of older people does not belong in Canberra, as recommended by the NHHRC. Every sector needs to work together to keep people at home as long as possible, supported by good e-health, using community nursing and local pharmacists, as well as general practitioners, subacute (rehabilitation) hospitals and nursing homes. These institutions are far cheaper to build and operate than acute hospitals. Acute hospitals have large numbers of older people in beds, blocking elective surgery and supporting emergency care. Devolving national responsibility for hospital management all the way to small Local Hospital Networks, with Australian Government performance indicators and casemix funding of 60% of “efficient costs”,1 will leave many hospitals in dire straits in those states where unit costs are far higher that in Victoria (the model for casemix funding). States will have to pick up the tab for much more than the 40% envisaged in order to keep many hospitals solvent. Even in Victoria, there are 40 regional hospitals that have to operate on block grants because casemix cannot adequately recognise services they need to provide for their communities. There will be a need for continuing state health department roles to supplement a new federal health bureaucracy in every state, with the Local Hospital Network boards having to respond to both. The NHHRC thought it had ended the “blame game”, but with two tracks for funding and decision making on every issue, including major equipment, hospital capital and maintenance, let alone separate tracks for the many aspects of aged care, there is huge potential for blame shifting. I urge devolution to larger regional clusters, each built around a public university with a Faculty of Medicine and Health Sciences, which can bring understanding of the roles of the professions. These would have the capacity to build an interface between hospitals and primary care, and to integrate the role of nurses — not only in hospitals but in community care of older people — and of physiotherapists, who have much to offer in rehabilitation and aged care, especially as cheaper subacute (rehabilitation) hospitals are developed. The prime role of the Department of Health and Ageing in Canberra should be policy. The regional clusters should represent a tripartite relationship between federal government, state government and university, with the state health minister having a role in governance and in coordination of statewide services. The clusters would then be the one-stop shop for major decisions, and blend the several streams of funding. Clusters should be free to contract for services from either the public or the private sector on the basis of cost and quality, and major hospitals across the country should become incorporated entities competing for contracts, with incentives to control burgeoning administrative staff numbers. The system would take several years to settle down, but it is the long term that matters — not a quick fix. Details of the model proposed here can be found at <http://www.grattan.edu.au/publications/011_penington_health_cluster_proposals.pdf>.

David G Penington AC

Starting with the basics of public hospitals and federal–state financial relationships The Australian Government’s policy statement of 3 March 20101 is the first of what will be a series of announcements on health policy and funding. It is nearly all about public hospitals and federal–state financial relationships. We will have to see if and how the later announcements interact. However, access to hospitals is the biggest single issue in the public mind. The basic issues are clear. The states and territories own and operate public hospitals under 5-yearly cost sharing agreements with the federal government. The initial shares were 50%–50%, but the Australian Government portion had steadily fallen to a low of 42% by 2007–08, and will be only slightly higher by the end of the current agreements in 2012–13. The policy report correctly identifies the major problem as the inability of the states to fund their share from their own resources. The Australian Government has the money and it must pay more; but that has been obvious for years. The Australian Government’s response is the one that, short of a complete takeover, gives it most influence and power. It intends to increase its contribution to 60% of “efficient cost” for all public hospital services, initially for inpatients but later also for outpatient and emergency department visits. Hospitals would be paid directly, not through the state health departments. For inpatients, payment would be determined by casemix, and for outpatients and emergency visits by some as yet unknown formula. The states would meet the remaining 40%. To recover the cost, the federal government has signalled a reduction of 30% in the states’ and territories’ Goods and Services Tax (GST) revenue, leaving the status quo intact. For the first time, the Australian Government will share in actual utilisation growth. But none of this will happen quickly. Until 2013–14 — two elections ahead — total funding will be the same as in the current Australian Health Care Agreements. The so-called $50 billion reform package is largely spin, derived by summing the higher federal government share of specific service payments over 15 years, and ignoring the fact that it is already paying that money through the distribution of the GST. The projected gain of $15 billion to the states and territories may be an overstatement too, because shortening waiting times for elective surgery — as the government is promising — will require more admissions and more money, of which the states will have to find at least 40%. The same basic problem, redefined. How does the reform plan hope to get more out of the system? Shorn of all the hype, there are only two measures available — casemix payment and the devolution of administration. Casemix payment is the new health economics religion. It is supposed to reward hospitals that treat most patients for a given amount of money and penalise those that treat fewer patients. Financial incentives rule. However, casemix numbers are only an approximate indicator of hospital output, and no large system, here or overseas, has ever paid hospitals exclusively on the basis of casemix. There is always a block grant component — for some hospitals, almost entirely. That is where the state administrations come in. They moderate the casemix evidence with other information and, unless the Australian Government intends to also prescribe how they must pay their 40% share, they will continue to do so. Casemix is a very useful analytical tool — it is not a panacea. The second measure is the creation of Local Hospital Networks that would be independent statutory authorities with which the state health departments would contract for the delivery of services. The arguments are much the same — this would encourage innovation and arrangements that suit the local community. However, that is not the main purpose. The whole thrust of this part of the plan is to assure health professionals, particularly doctors, that their positions would be restored and enhanced under more local arrangements. The barely concealed objective is clear — restructuring the state hospital administrations, particularly the two most centralised ones in New South Wales and Queensland. The idea is probably popular there, although I doubt if it has anything like the same trenchancy elsewhere. There is a good case for more administrative devolution. All organisations atrophy; periodic shake-outs are no bad thing, and it would satisfy many vocal groups. However, the proposed Local Hospital Networks are both vaguely defined and impractical. They would be absurdly small. Contiguity is not the prime consideration — structural relationships are, and every state has well defined referral patterns of a vertical kind. The small-scale model might make some sense in rural areas, but it is impossible to see it working in the major cities where 70% of Australians live, the big teaching hospitals dominate, and the whole city is effectively a region on its own. Will all this reduce the blame game? Of course not. This policy document is full of it. There is some conflict with the concept of federalism agreed by the Council of Australian Governments (COAG) in 2008, under which the federal government would set outcome targets for broad programs only, leaving the states free to manage them. The new proposals will retain state management but force some organisational changes on them. However, that may well be inevitable and the consequences would be much less radical than the political rhetoric on both sides suggest. It is a significant bureaucratic change though, and, with the next COAG meeting scheduled for 11 April, it is a big ask to seek acceptance in a month.

John S Deeble AO

Health is complex and so is health reform The final report of the National Health and Hospitals Reform Commission (NHHRC), published in June 2009,1 provides a blueprint for major reform of the Australian health system — reform that is long overdue and that is vital if we are to meet the future health care needs of the Australian people. The release of the Australian Government’s national health reform plan2 on 3 March 2010 marks an important milestone. After much listening, thinking, debate and deliberation, it is now time to start taking action. This, the first in a series of announcements by the Australian Government, focused on proposed changes to governance and public financing structures. Public hospitals, general practice and primary health care, health workforce and e-health were flagged as key further elements of the reform plan to be released over the coming weeks and months. As pointed out in the NHHRC report, “we have a fragmented health system with a complex division of funding responsibilities and performance accountabilities between different levels of government”.1 The current separation of responsibilities means that no level of government has a detailed understanding of all aspects of the health system. It is therefore not surprising that this first part of the plan sets out “major structural reforms to establish the financing and governance foundations of a National Health and Hospitals Network for Australia’s future”.2 However, high-level structural changes alone cannot and will not rectify all the current problems and emerging challenges faced by our health system. The NHHRC concluded that fundamental structural reform is required to remove obstacles and enable the system-wide reforms presented in its final report. A key message of the NHHRC’s work on governance is that we need to move beyond the blame game and create “one national health system” with local flexibility and innovation in delivery. The NHHRC presented a pathway, similar to that described by the government, with clearer roles and accountabilities for governments, and with the Australian Government taking greater financial responsibility, which could be increased over time. This would enable the states to continue to plan and operate public hospitals and health services. Local clinical and community engagement were emphasised, and system-wide clinical governance and a teaching and research-led quality agenda were recommended. A number of these features are reflected in the national health reform plan’s approach to restructuring governance and financing arrangements. Under the new arrangements, public hospitals and health services would be funded nationally and run locally. The Australian Government would be the dominant funder of health care, with responsibility for 100% of public funding of primary health care, and 60% of hospital activity, including teaching, research and capital costs. This represents a significant exposure for the Australian Government, which is important in sustaining public financing of the system. The reform plan’s clear statement about state government revenue growth not being able to keep pace with growing health care costs is critical, not only as one of the reasons why greater federal funding responsibility makes sense, but also to acknowledge the financing pressures that states, and therefore public hospitals, have faced and will continue to face without such change. The planned Local Hospital Networks provide a mechanism for local flexibility and innovation, with greater clinical and community engagement and control. States would have a key role in service and capital planning, determining network structures, and appointing the governing council. The size, range of services and geography of Local Hospital Networks would be determined by the states with consideration of local needs and circumstances. One “size” will not fit all. A hospital activity-based funding system will contribute to consistency, transparency and efficiency. The proposed “arms-length” expert pricing body that will be responsible for determining a nationally consistent approach to hospital funding is a welcome feature. The establishment of this body recognises that a range of issues will need to be addressed, including cost weighting for rural and Indigenous health care needs, and establishing funding mechanisms for areas of service not suited to an activity-based funding approach. Direct payment to Local Hospital Networks, as flagged in the NHHRC report, will increase transparency and radically change the dynamic of public hospital management, from one of avoiding activity to contain costs to one of optimising activity to attract direct payment. National standards should also offer greater transparency, increase accountability, reward good performance and better inform the community about the quality and outcomes of our public and private health services. The NHHRC recommended that these standards be developed with clinical, economic and community participation, and that they should cover all aspects of the health service continuum — such as getting access to a general practitioner, timely response in a mental health crisis, and getting to see a specialist or access a rehabilitation service — so that surgical and emergency waiting times alone do not dominate the agenda. These reforms would arguably be the most significant changes to governance and public health financing in Australia over the past 30 years. While good governance and sustainable funding are critical enablers, they are not the whole reform story. The next chapters of the reform plan must demonstrate that this framework will ultimately translate into better, connected health care across all settings and for all Australians.

Christine C Bennett MB BS, FRACP, MPaed

There is no certainty that the new finance arrangements will reduce inequalities in access to care After a prolonged gestation, we are now witnessing the somewhat protracted birth of the Rudd Government’s health reform plan. To date, only the head of the new scheme has come into view.1 For those who remain anxious about the overall health of the infant, and indeed whether it has all of its necessary parts, we have been provided with an attractive slogan — “funded nationally and run locally” — rather than a clear blueprint for action. It may surprise and distress many Australians to learn that our health system is ranked 32nd in the world for overall performance.2 The main reason for this rather ordinary outcome is that we have progressively institutionalised a chaotic and increasingly inequitable system. The National Health and Hospitals Reform Commission clearly identified a range of major problems that should be the focus of any proposed changes.3 These included: lack of sustainability, which included finance, infrastructure and manpower; lack of access to key services, specifically highlighting mental health, dental and aged care services; divided responsibilities for care, not only between the federal government and the states, but also across the private–public and hospital–community sectors; growing health service inequalities, notably affecting Indigenous peoples and those who live in rural and regional communities; lack of continuity of health care that results in poor quality, high cost and largely ineffective forms of care for those with chronic illnesses; and lack of routine use of data monitoring to drive increased clinical and financial accountability. The Prime Minister’s first health reform announcement focuses narrowly on increased federal government support for public hospital financing.1 This is an essential first step and will clearly be welcomed by the wider Australian community. There is no doubt that the decline in confidence in our public hospitals is based largely on the belief that they have been starved of funds. The proposal to now extend the 1990s activity-based funding model across the nation responds directly to that concern. Fortunately, it has been updated in 2010 to recognise the need to reinvest in research and training, as well as support ongoing infrastructure development. Although it is not clear when substantial new monies will enter the system, at least we are headed for the situation where the government that collects the most tax will now pay most of the increasing costs. Importantly, governments in Australia now fund only 70% of all health care costs.4 This gap is high by international standards, and in recent years there has been a clear trend towards transferring increasing costs to those who fall ill. Obviously, this has its greatest impact on those with chronic illness and those who have the least capacity to pay. Unfortunately, the new plan provides no details as to the ongoing roles of private hospital, medical or dental services. The ways in which private health insurance (or alternative health savings models) could be better used to supplement universal coverage are also not discussed.1 Consequently, it is uncertain whether the new finance arrangements will actually lead to a reduction in the current inequalities in access to timely care. The other key structural change, namely the introduction of Local Hospital Networks,1 is a direct response to the health professions’ and the wider public’s lack of faith in both federal and state health bureaucracies. While this is obviously smart politics, it is not necessarily smart health policy. The dangers of further Balkanisation of health planning, greater fragmentation between hospital and community-based services, and the promotion of intense local service rivalries are obvious. Unnecessarily, the local network plan is hospital-centric and bound to perpetuate the blame game between these federally funded but state-governed local authorities. As new regional health care organisations are progressively introduced to lead the next round of primary care reform, the existing gaps between local hospitals and community-based services may worsen. We will now have 120–150 Local Hospital Networks that are structurally disconnected from 50–60 new general practice-based primary care organisations. Meanwhile, other more specialised community services such as mental health, alcohol and drug services, and maternal and child health services have been left in limbo. Without a clear national commitment to finance and run these systems, the most likely outcome is that they will be left to rot under the existing state-based funding models.5 Given the increased community focus on these issues,6 the continuing lack of attention to their future sustainability is inexplicable. For the Rudd plan to achieve real credibility, it needs to explain how a 60-year-old man in rural Australia without private health insurance will now get a timely hip replacement or affordable cataract surgery. Even more challenging are questions such as: how will a 50-year-old Indigenous woman with diabetes, arthritis and dental decay get access to the primary care, dental and other allied health services that she really deserves; or how will a 19-year-old man who has recently attempted suicide receive the ongoing help he desperately needs? If Mr Rudd cannot easily explain how the new system will assist these people, then the current round of national health reform may well be stillborn.

Ian B Hickie AM, MD, FRANZCP, FASSA

Key arguments of the recent proposal for health reforms are questionable Prime Minister Rudd is to be applauded for shaking the logjam of federal–state health relations, which for some time has been identified as a stumbling block to improving the health system. But that is all. His proposals as we currently know them have superficial appeal, but from a longer-term perspective they are a poisoned chalice. The alleged advantages of the Commonwealth assumption of power are, at best, overstated. Although the Commonwealth has greater fiscal power and can ensure stable, long-term funding, it would be better to reform the tax system to meet the needs of the health system than compromise health care delivery to match an antiquated tax system. As noted in two articles in the Journal (recently published online), these reforms will not end blame-shifting.1,2 With a political incentive, some argument will be found. For example, the states will be accused of inadequate capital expenditure on infrastructure, and the Commonwealth of case payments that are too low. Diagnosis-related group (DRG) casemix payment for hospitals is undoubtedly a good idea. But there is no reason to believe that it will have a major system effect. It will not balance the mix of primary, secondary and tertiary care, ensure quality in hospitals, integrate programs, improve access to services, or even ensure internal reforms within hospitals. Queuing is a function of funding relative to demand, with or without DRGs. In view of innumerable special circumstances, it is very unlikely that the Commonwealth could run such a DRG system without simply replicating much of the work presently carried out by the states. A direct pipeline to federal funds will further maximise the incentive for special pleading and political pressure and, as clearly demonstrated in the 2007 federal election, this can be highly effective. Former Prime Minister Howard’s intervention in the funding of the Mersey Hospital in Tasmania during that election gives a preview of the special pleading and pressure which might be expected under future governments. However, the chief concerns are the long-run implications of the takeover and the lack of consideration of the relevant arguments and evidence (which were not provided by the National Health and Hospitals Reform Commission [NHHRC]).3 For the past two and a half decades, the major issue in the literature concerning health system reform has been the achievement of a system framework permitting patient choice of scheme (ie, diversity). In Australia, the arguments for this were vigorously promoted by Richard Scotton (one of the two architects of the original Medibank scheme and subsequently a Professor of Health Economics at Monash University)4 and briefly discussed by the Productivity Commission.5 But the discussion of the Scotton plan largely ceased with Scotton’s retirement and his name appears only once in the NHHRC report in a footnote.6 The case for diversity is compelling and draws on insights from the greatest economists, as distinct from the flawed theories embodied in recent orthodoxy. Adam Smith, the father of modern economics, famously summed up the case against centralised control when he argued that: The man of system ... seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board ... but ... in the great chess-board of human society, every single piece has a principle of motion of its own.7 Failure to heed this message led to excessive micromanagement, regulation and control by government, which culminated in the conservative backlash that started in Chicago and led to the Thatcher–Reagan era. John Maynard Keynes — the 20th century’s greatest economist — described a world characterised by uncertainty and unknowability of future context-specific challenges and the need for pragmatic flexibility. He even conceded the possibility of a budget surplus during depression times if, hypothetically, that happened to be the linchpin of business confidence.8 Failure to heed this message gave rise to a theory of finance based on statistical confidences, now discredited by the collapse of world financial markets. The response, at least, was flexible and pragmatic. The take-home message from these great economists is that in the face of technological and other changes, systems and institutions must be adaptive and that this is unlikely, in the long run, when they are dominated by a “master manipulator”. Consistent with this, Eric Beinhocker, Senior Fellow at the McKinsey Global Institute, has described the economy as a complex adaptive system, akin to the brain, the internet or an ecosystem.9 The conclusion of his masterly review in The origin of wealth is that the great lesson of the 20th century for political economy is that monopolies fail. Successful enterprise has been characterised by error learning and reinvention. Rudd echoed this conclusion when he argued that “big departments risk becoming less accountable, less agile, less adaptable and more inward-looking”.10 But this was in the context of homeland security. The historical success of the competitive market has little to do with the static properties taught in economics textbooks and everything to do with creating a flexible, adaptive system characterised by error learning or bankruptcy. Information is conveyed by prices, and price flexibility is the key to long-run dynamic efficiency. No part of the economy is more complex than health care. However, the health sector cannot duplicate the competitive market in its simple form for technical reasons and because of its social role. The long-run challenge is therefore to devise a system which carries out this role with diversity, flexibility and error learning. Concentration of power in a monopolistic Commonwealth system is the antithesis of this. Government has, increasingly, been characterised by error suppression and marketing. With the conversion of the public sector into an instrument for fulfilling political goals — driven by short-run contracts and bonuses — government is increasingly becoming the problem, not the solution. To believe that the federal government is likely to achieve efficiency in the long run requires ideological blinkers and amnesia. A short list of problems which have been known and ignored for decades includes Aboriginal health, quality of care (200 unnecessary deaths per week), geographic and other dimensions of fairness, program coordination, and effective integration of private health insurance into the health system. The rhetorical rejoinder, of course, is that it is because of these problems that we need a Commonwealth takeover. But in addition to their lack of both experience with running hospitals and knowledge of local considerations, the Commonwealth has had the power and resources to effect major reforms in the past but is on record as preferring to ignore the politically sensitive problems.11 Rudd may be different. However, there is little evidence to demonstrate this. And we must not lose sight of the long-term context: what about the next government, and the next? The track record and trend in government gives no reason to believe that policy will cease to be driven primarily by interest group appeasement, with the public mollified by marketing and spin. The process that Rudd has followed reinforces this conclusion. The NHHRC report, which the government ostensibly drew on, offers no serious discussion — evidence or argument — to support the new policy.6 The world literature and experience concerning these issues were largely ignored, at least in the published report. The case against diversity and experimentation in primary health care is simply asserted: “Our recommendations for ... comprehensive primary health care ... require one government — the Commonwealth Government ... Thus we recommend that the Commonwealth Government assumes full responsibility for primary health care services”.6 The balance shown in the NHHRC’s judgements may also be questioned. In one of its few references to adverse events, it notes that “admission to hospital is not without risk”.12 It is also true that the Sahara Desert has dry bits. Alternatives exist which increase the probability of error learning and evolutionary improvement. The key element is a degree of diversity — a non-monopoly. Devolution to large clusters has been recommended, and a model for this has been provided.2 Similarly, I have previously advocated “managed government competition”, in which the emphasis is on de-politicisation and elements largely missing from previous discussions — the creation of governance and information flow that forces error learning and rapid uptake of good new technologies.3 In the long run, these elements are more important than the cash flow and budgetary considerations that dominate much of the present discussion and decision making.

Jeff R J Richardson PhD

We are waiting for the details — without these the plan will fail The Rudd hospital reform plan1 could be better. That said, it does have the potential to be a significant improvement over what we have now. No doubt it would be better to have one level of government assume 100% of health funding. But that was never going to happen. So it’s time to accept that and move on. As others have observed, the devil will be in the detail. It is vital that the detail is right, even if it takes longer than planned. The first bit of detail to get right is what we call a hospital. A hospital is no longer the big white building that sits at the top of the hill. Hospital-in-the-home care is now the norm for many conditions, and the proposed new model won’t work if the new Local Hospital Networks (LHNs) only include the big white buildings rather than the associated community and home care that many patients require. Not everything that happens outside the walls of a hospital can be neatly packaged as “primary care”. Community mental health and palliative care at home are two examples. What we really need are “local health networks”, not networks of white buildings. And those networks need to be organised in support of, and include, primary care. If we don’t improve at managing chronic disease, providing required rehabilitation and preventing complex conditions from becoming worse, then the health system will continue to lurch from crisis to crisis, regardless of who manages it or how it is funded. Effective systems to establish the right balance of investment between acute, subacute and primary care are critical. The second bit to get right is how we plan for the growing and changing health needs of our population and how we achieve more equitable health funding across and within states and territories. The Rudd plan is weak on this point — paying for what’s on offer by the LHNs isn’t good enough. While the LHNs can do the micro-planning, the Rudd plan is silent on who will be responsible for making sure that each community and region across Australia will get its fair share of the pie. There are problems with the New South Wales health system. However, the commitment of successive NSW governments to improving population equity (through the Resource Distribution Formula2) is without doubt one of the strengths of that state. We need something similar on a national basis. Under the Rudd plan, while states and territories will be responsible for “local activity targets, service mix and provision for highly specialised services” as well as “capital planning management”,1 there is no requirement for them to improve equity of access. And the plan is silent on whether the Rudd Government will try to improve funding equity across, as well as within, states and territories. If it is going to, it might want to look in its own backyard and address the current inequity of access to Medicare. Efficiency is discussed at length in the Rudd plan, but it is just one side of the equation. Equity is the other. The principle of population equity needs to be, with efficiency, front and centre in the detail of the Rudd plan. If it is, it will no doubt go a long way to alleviating the current anxiety about the future of rural and remote health care. The catchment size of each LHN will be critical to the equity question. Rather than planning around the number of hospitals (one to four is the current plan1), it would make more sense for LHNs to be planned based on the number of people living in the local catchment area. Each LHN needs to be responsible for meeting the basic health and hospital needs of the people who live locally, with teaching hospitals being responsible for providing more specialised care when needed. For the bush, that implies LHNs servicing populations of 50 000 to 250 000. Regional and urban networks need to be larger, covering typical populations of 250 000 to 500 000, although some densely populated capital cities need LHNs to service populations of up to 800 000. And that leads to the next bit of detail that it is vital to get right. The efficient price at one type of hospital isn’t the efficient price at another. Rural and remote hospitals cost more, not because they are inefficient but because of cost factors beyond their control. Likewise, hospitals in a major expansion phase cost more than those doing the same as what they did last year. The key point is that the pricing model will have to be sophisticated and have the capacity to be adapted to local circumstances. We certainly shouldn’t be rewarding the inefficient. But, on the other hand, we shouldn’t be punishing hospitals for factors beyond their control. Just as we need equity between communities, we also need equity between providers. And there’s more to an equitable funding model than simplistic measures of technical efficiency. It won’t require the wisdom of Solomon, but it will require expert planning and competent technical work. The federal government has no experience in funding or managing hospitals and certainly lacks the technical expertise. At the state and territory level, the expertise is patchy. The state with the most experience in activity-based funding, Victoria, is in many ways the easiest health system to run. With its small geographical size and population concentration in Melbourne, it has no experience in the challenges of funding or running hospitals in remote communities.3,4 It also has one of the smallest Indigenous populations in the country5 and, compared with other states, has little experience in either pricing or delivering Indigenous health care. For these and other reasons, the national efficient pricing model will need to be considerably more sophisticated than the current Victorian approach. Finally, despite all the rhetoric, the plan as proposed so far is a long way from ending the blame game. Instead, the Australian Government will call all the shots, while the states and territories will be blamed for all the problems. While no doubt appealing to federal politicians, this won’t create the sustainable health system needed in the years ahead. The detail we are all waiting for needs to include effective systems for joint decision making and shared responsibility and financial risk sharing between the federal, state and territory governments. Without that, the Rudd plan is bound to fail.

Kathy Eagar MA, PhD, FAFRM(Hon)

A sharp increase in the number of students graduating from Australian medical schools over the next few years looks set to outpace available intern positions. Graduating overseas students will be the first to miss out. While this treatment of overseas students is unlikely to be found unlawful, questions of fairness remain. From a policy standpoint, the bottleneck in intern places could be quite damaging as: it encourages Australian-trained medical graduates with high-quality training and culturally-relevant skills to leave; and it extinguishes a valuable opportunity to steer some of these graduates into geographical areas with the greatest medical workforce needs.

Katie J Elkin LLB(Hons), BSc · David M Studdert LLB, ScD

As the population ages, the prevalence of aortic stenosis is increasing. There is an unmet clinical need for the treatment of aortic stenosis in high-risk patients, who are often older, frail and have multiple comorbidities. Percutaneous aortic valve replacement (PAVR) is a new and innovative technique for the management of high-risk patients with aortic stenosis. There are currently two devices under evaluation in clinical trials in Australia: the CoreValve ReValving System and the Edwards SAPIEN valve. These devices are generally deployed retrogradely, mainly transfemorally or via the subclavian artery or, less commonly, transapically. Initial experience has been encouraging, with good short-term outcomes. However, there is a lack of long-term data. PAVR is presently only advocated for high-risk older patients with symptomatic aortic stenosis. Where PAVR lies in the treatment algorithm for aortic stenosis will be determined by randomised controlled trials, but for now it offers a genuine treatment alternative for high-risk patients.

Jamie J Layland MB ChB, MRCP, FRACP · Brendan Bell MB BS, FRACP · Dan Mullany MB BS, FRACA, FJFICM · Darren L Walters MB BS, MPhil, FRACP

Australia faces a federally instigated migration drive aimed at increasing its population to 35 million by 2049. Immigration is welcomed by politicians, economists and businesspeople, who credit it with helping Australia fare better than other developed countries during the recent global financial crisis. Australia’s capital cities will have to expand considerably to house the new migrants. Increased urbanisation, when not accompanied by appropriate town planning, is associated with higher rates of chronic disease. Despite the migration drive, Australia’s population will continue to age, and by 2056 one in four Australians will be over the age of 65 years. Australian health services are already heavily burdened. Health professionals must engage with governments to ensure that appropriate plans are put in place to accommodate the increased burden of disease that will accompany a more populous Australia. Failure to do so will compromise the health of our nation.

Deborah Pelser BSc, MB BCh

In this article, I examine all the attempts to reform Australia’s health insurance system since Medibank was introduced in 1975; there have been seven, and the eighth (which goes beyond just health insurance) is now in progress. I argue that the Rudd Labor government should take heed of history’s lessons and reduce the pressure for ongoing structural reform. The lessons of history suggest that tipping the balance too far in favour of public or private insurance is not sustainable, and nor is setting the two schemes up in competition with each other. The challenge that faces the Australian Government now is to design a health system that integrates the public and private insurance schemes in a way that is economically sustainable. If it does not, major structural reforms to the health system will be needed again in the near future.

Anne-marie Boxall PhD

Obesity, ill health and global warming are linked. The risks to health of climate change have been well articulated but have not been accompanied by clear policy and effective action. Four areas where doctors can and should act, and where changes will benefit both the environment and human health in the short-to-medium term are: reduction in the adverse environmental impact of the health care industry; development of a nationwide comprehensive food and nutrition policy that takes account of the entire food production cycle; urban redesign to encourage active transport; and more support for sexual and reproductive health services in developing countries. Finally, climate change policies should be assessed for their impact on global health and equity.

Robyn A McDermott MPH, FAFPHM, PhD

Clinical records Patient 1 A 6-year-old boy briefly sat on an uncovered drain site in a home swimming pool. He extracted himself but his intestines could be seen prolapsing from his anus. On transfer to tertiary care from the local hospital, severe hypovolaemic shock was noted. He received aggressive fluid resuscitation and blood transfusion before undergoing an emergency laparotomy. This found a shearing injury, with complete disruption of the mesenteric vessels and a massive haemoperitoneum, but no active bleeding. A 4 cm anterior rectosigmoid tear was noted, through which 110 cm of small intestine had herniated out via the anus. This length was non-viable. The patient was left with 55 cm of small intestine, with an intact ileocaecal valve. The rest of the colon was normal, and there was no injury to the perineum. Primary closure of the rectal perforation was performed, and both ends of the small bowel were exteriorised. After the operation, the patient was managed with total parenteral nutrition, and loperamide to slow stoma output. Six weeks later, he underwent closure of the stoma. The boy’s long-term growth, diet and continence are normal, although his bowel motions remain loose. Patient 2 A 4-year-old girl sat on a home swimming pool skimmer box and was unable to get up again. Her father broke the seal around her buttocks, and evisceration was immediately apparent. She was taken to the emergency department at a major regional centre, where she was intubated and transferred to tertiary care. A laparotomy found that 75% of the small bowel had prolapsed through a rectal perforation just above the peritoneal reflection. There was a large mesenteric tear, with avulsion of the superior mesenteric vessels. There were 120 cm of jejunum proximally and 90 cm of ileum distally that were viable. The rectal perforation just above the peritoneal reflection was repaired. Over the next 4 days, two laparotomies were performed and non-viable bowel resected on both occasions. The patient was left with 140 cm of small bowel, an intact ileocaecal valve, and a loop sigmoid colostomy. Oral intake commenced on the 11th day, and parenteral nutrition ceased after 16 days. She was discharged after 21 days. The colostomy was closed after 14 weeks, and the girl was well at 6-month follow-up, with normal continence. Patient 3 A 3-year-old boy sat down on an uncovered skimmer box when he baulked while preparing to jump into a pool at a motel. He was initially taken to a small regional hospital then transferred to tertiary care. At laparotomy, the small bowel, from 20 cm distal to the duodenojejunal flexure to the ileocaecal valve, was found to have been eviscerated. There was a 20 cm section of jejunum proximally that had its mesentery stripped off; this was resected and the ends stapled. The rectal perforation just above the peritoneal reflection was repaired. At a second-look laparotomy 2 days later, a further 5 cm of the distal bowel was found to be frankly necrotic, and was resected. The remaining distal bowel had marginal viability, as assessed by intraoperative pulse oximetry, but was left in situ to maximise bowel length (170 cm of small bowel). Postoperative management was complex: epoprostenol (prostacyclin) and dopamine were commenced to promote bowel perfusion. A third laparotomy showed improved perfusion and continuity was restored. The patient had a difficult postoperative course, with prolonged parenteral nutrition, sepsis and an enterocutaneous fistula. The fistula closed spontaneously, enteral feeding was established and he was discharged after a 3-month hospital stay. At 1-year follow-up, the boy was active, tolerating a full diet, continent by day, and above the 90th percentile for weight and height. His wound had healed well except for two slightly keloid areas. The causes of these evisceration injuries are well described in the literature. Vortex-style drains can create a powerful vacuum when occluded.1 In addition to the transanal route, direct evisceration through the perineum has been described.2 Other non-suction-related causes of transanal evisceration have also been described — in adults, it is usually associated with increased abdominal pressure or blunt trauma. This is a rare occurrence in adults, with only 53 reported cases.3 Non-suction-related transanal evisceration in children has only recently been described in relation to accidental and self-inflicted rectal trauma.4,5 The potential for penetrating trauma to cause evisceration should be considered by the astute clinician if the history or physical findings are not consistent. Associated perineal oedema and petechiae are well described with suction injuries. Entrapment in deeper water has also resulted in drowning.6 There can be a spectrum of injury associated with this mechanism, and treatment should be tailored accordingly. At the mild end of the spectrum, prolapse of the rectum can occur, which can be treated with simple reduction.7 True transanal evisceration always requires operative repair and often multiple procedures.1 In the patients described here, the bowel was difficult to reduce and required gentle pressure from below with guidance via laparotomy from above. The injury to the bowel in all cases was due to the traction on the mesentery and subsequent damage to the mesenteric vessels. This is in contrast to reported cases of evisceration from penetrating injury, where the eviscerated bowel was viable and otherwise intact.4,5 Patients 2 and 3 illustrate the importance of second-look laparotomy in the evaluation of bowel of questionable viability, as has been highlighted in the literature.1,6 Bowel that is initially of dubious viability can later be found to have survived, thus preserving length and avoiding complications of short bowel. The use of pulse oximetry to aid in determination of bowel viability has previously been described8 and was helpful in avoiding massive resection in our third patient. Prostacyclin analogues have been shown to have a beneficial effect on splanchnic perfusion in animal models and in human studies.9 There is considerable morbidity associated with this condition. The most minor form of injury can be a transient rectal mucosal prolapse with no perforation, but, even at this end of the spectrum, there is considerable psychological impact.7 At the most serious end of the injury spectrum, short bowel syndrome can occur, with an ongoing requirement for parenteral nutrition, and potentially even death following small bowel transplant.1,2,6 A 2007 review of published cases found that nine of 13 patients were dependent on parenteral nutrition.10 The lengths of bowel lost through these injuries are graphically represented in Box 1. By comparison, our patients had good outcomes, with no ongoing requirement for parenteral nutrition. There is growing literature suggesting that suction drains are not necessary for pool cleaning, and that more effective, safer alternatives are available.11,12 If a suction drain is newly installed or is already in place, protective, or antivortex, covers have been advocated to minimise the suction risk.1 Although these covers will prevent direct suction injuries, hair or digits could still be trapped, and the covers only offer protection when fitted correctly and not removed. Two of our patients’ injuries occurred because the covers had been temporarily removed. In addition to the inherent danger of the pool suction drain, the arrangement of the drain in two of our cases made it even more inviting for a young child to sit on when uncovered (Box 2). Changing the shape, size and configuration of the aperture may therefore also prevent injury. Other potential remedies are adding an automatic cut-off switch so that the filter cannot function if the cover is off, or an override system that cuts off the filter if the intake appears to be occluded, thus limiting the peak negative pressure that can be generated. The role of legislation with regard to education also needs to be considered. There has been a voluntary standard for swimming pool drains in Australia since 1980, and this was updated in 2003. This document mandates that any access hole greater than 150 mm in diameter be separated from the pool edge by a solid permanent beam of at least 100 mm width and be covered by a vented lid.13 The ongoing incidence of these injuries shows that this approach alone has failed to protect children. The “four Es” of injury prevention — education, engineering, enforcement and economics — have previously been described.14 Rather than a voluntary standard, legislation is needed to mandate the safety of swimming pool fittings, as has been the case with pool fencing.15 Enforcement of such legislation is also required to effect change.16 Finally, public education has been shown to be effective in injury prevention in other areas.17 These suction injuries are rare but potentially catastrophic. It is important to publicly highlight the danger of these injuries and effect change before more children are maimed. 1 Length of bowel resected* in our three patients and eight other cases1,2,6 of transrectal evisceration * Length of bowel resected is represented by shaded area. 2 “Potty” style skimmer box This is the location at which Patient 3 was injured. The brown structure to the left is the cover that is intended to sit over the skimmer box. Lessons from practice Evisceration injuries caused by the suction of swimming pool drains are rare but potentially catastrophic events. Delayed resection can minimise the chance of short bowel syndrome in evisceration injuries. Although current engineering standards are adequate to prevent these kinds of injuries, education of pool owners and ultimately enforcement of legislation are required to ensure that standards are enacted.

Neil R Price MB ChB, FRACS(Paed) · S V Soundappan MS(GenSurg), MCh(PaedSurg), FRACS(Paed) · Anthony L Sparnon FRACS · Danny T Cass FRACS

To the Editor: From 30 September 2009, the Australian Government began offering free pandemic (H1N1) 2009 influenza vaccine (Panvax, CSL Limited, Melbourne, VIC), using either 10-dose (5 mL) or 20-dose (10 mL) vials.1 Multidose vials are not used routinely in Australia, and are designed for high-volume vaccination clinics.2 Once pierced, a Panvax vial must be used within 24 hours or discarded.3 We investigated vaccine wastage in general practice during the first month of the vaccine’s availability. We randomly selected 300 of 697 known general practices within the Sydney South West Area Health Service. A one-page audit of vaccine vials received and consumed, and of patients vaccinated to 31 October 2009 was faxed to practices. One reminder fax was sent. Faxes were successfully delivered to 271 practices and 146 (54%) responded. Twelve responses (4%) were substantially incomplete, leaving 134 (49%) for analysis. Practices reported vaccinating 28 445 people. A median of 70% (interquartile range, 50%–90%) of people immunised belonged to a priority group. An estimated 49 130 doses were consumed, indicating that 20 685 doses (42%) were wasted. A median of 40% of doses were wasted per practice. Three practices (2%) had administered only one dose per multidose vial. There was significantly less wastage in practices with access to 5 mL vials (median wastage, 30%) than practices that had only 10 mL vials (median wastage, 50%) (P < 0.001; Wilcoxon rank-sum test). There was no significant difference in the proportion of doses wasted between the 70 practices that organised vaccination clinics and the 63 practices that did not (median wastage, 43% v 40%; P = 0.9; Wilcoxon rank-sum test). There was also no statistically significant difference in the proportion wasted between solo and multidoctor practices (median wastage, 43% v 34%; P = 0.2; Wilcoxon rank-sum test) although the absolute wastage level was lower for multidoctor practices. These results provide evidence that multidose vials (discarded within 24 hours of first use) are an inefficient method of presenting pandemic influenza vaccines for general practice use. Wastage was substantial. This study is limited to the program’s first month, so initial results may not reflect results over the whole program. However, if similar wastage occurred nationally, over 7.5 million of the 19 million doses available to Australians could be wasted. Nevertheless, the low unit cost and rapid production advantages of multidose vials may justify their use when faced with an urgent threat, and if used in mass vaccination clinics. Wastage could be reduced by increasing the availability of 5 mL multidose vials, but not (according to our data) by organising general practice vaccination clinics. Extending the vaccine shelf-life from 24 hours to 28 days, to align with licence conditions in the United States,4 could decrease wastage, as it may be that the short shelf-life results in more wastage than does supplying the vaccine in multidose vials. No rationale for the shorter shelf-life in Australia has been found, but we surmise it was set as a precaution to reduce the risk of contamination. Doses saved through reduced wastage could be used to increase Australia’s donation of vaccine to developing countries.5

Caroline E Turnour · Stephen J Conaty · Michelle A Cretikos

To the Editor: In their recent article, Beaman and Leung raised a number of important and pertinent issues about what we can learn from the influenza pandemic of 2009.1 However, we would like to correct a number of misconceptions on their part, including claims that Western Australia’s central public reference laboratory, PathWest Laboratory Medicine WA, (i) unreasonably favoured polymerase chain reaction (PCR) testing over antigen testing; (ii) rationed and prioritised testing primarily because of inability to cope with the high demand; (iii) rarely achieved the benchmark turnaround time of 48 hours; and (iv) spent excessive time processing a large number of specimens, of which 96% were reported as negative. State reference laboratories had to provide tests that would best guide individual patient management and the most effective use of hospital beds, as well as informing the public health response. The decision to avoid antigen detection tests was supported by the World Health Organization from the beginning of the pandemic2 and confirmed by subsequent published data showing that PCR testing was more reliable than antigen testing.3,4 Inaccurate test results hinder rather than help the pandemic response,5 especially in the early stages. From very early in the pandemic, we prioritised samples from hospitalised patients, health care workers, people at higher risk of severe disease and cases of special public health importance. For these urgent samples we aimed for, and largely achieved, a 48-hour turnaround time. Beaman and Leung did not allow for the substantial delays in transport and processing of samples before testing, which contributed 2–3 days to the turnaround time. A similar experience was reported in Victoria.6 This has highlighted the need to improve the way in which samples are handled at all stages between collection and testing. Rationing of services was a decision made in consultation with our public health colleagues, to ensure sustainable testing capacity for essential clinical and public health needs. In the end, PathWest tested 24 310 samples, representing 92.8% of the samples received, which included all of the high-priority and/or critical samples. It is misleading to suggest that a 96% negative rate was inefficient, and is a misunderstanding of the purpose of testing in the different phases of the pandemic. In the early phases, the yield of positive test results was expected to be low, as there was active case-finding at a time when no or very little virus was present in Australia. Across the course of the pandemic, the positive rate at our laboratory was 23% overall and 40% during the peak week. The response of public and private laboratories to the pandemic throughout Australia was impressive, and has now been the subject of state and national debriefings to identify potential improvements and the highest priorities for action. As part of that, we should all look at how we could improve our own laboratory’s performance and how we could make the best contribution to dealing with future pandemics and other emerging infectious diseases, both as individuals and as members of organisations. We would like to take this opportunity to acknowledge all the people within and outside laboratories who made a huge effort to save lives and reduce the impact of the pandemic.

David W Smith · David J Speers · Rodney A Bowman

To the Editor: We report the case of a child who presented with intussusception due to heterotopic pancreas. A 10-year-old girl presented with right iliac fossa pain and nausea. She was febrile (38.4°C) and had right iliac fossa tenderness with guarding. When she started vomiting, she was taken to theatre with a provisional diagnosis of acute appendicitis. During the diagnostic laparoscopy, her appendix did not appear inflamed and she was found to have intussusception due to a 10 mm tumour in the ileum, about 80 mm from the ileocaecal valve. The tumour was resected, and microscopic examination showed the presence of ducts and lobules of exocrine acini, with occasional foci of islet cell tissue extending into the muscularis propria. These features were consistent with heterotopic pancreas. Heterotopic pancreas is defined as the presence of pancreatic tissue outside its usual location and without anatomic relation either of continuity or of vascularisation with the pancreas.1 Its overall surgical incidence has been estimated as one case in every 500 abdominal explorations at Mayo Clinic.1 During embyrogenesis, the normal pancreas arises from several evaginations originating from the wall of the primitive duodenum. If one or more evaginations remains in the wall of the bowel, it may be carried away from the rest of the gland by the developing gastrointestinal tract and give rise to heterotopic pancreas.2 In adults, the most common locations for heterotopic pancreas, in descending order of frequency, are the stomach, duodenum and jejunum.3 However, in children, the most common location is within a Meckel diverticulum.3 Heterotopic pancreas is usually asymptomatic, and most cases have been found coincidentally at laparotomy performed for other abdominal conditions.4 However, in some people, pathological changes such as inflammation, abnormal hormone secretion and cystic degeneration within the heterotopic pancreas have been reported to cause abdominal pain and discomfort.3,4 Isolated heterotopic pancreas in the ileum is very rare and usually asymptomatic. The lesion within the wall of the ileum may act as a lead point,3,5 and this is thought to be the mechanism of intussusception. It has also been postulated that intussusception arises from local disturbance in the motility of the small intestine caused by the heterotopic pancreas.3

Narotam R Jootun · Hock P Cheah · Siddath C Fernando · William S Munro · Martin Veysey

To the Editor: The recent article by Davis and colleagues reported that the SMART-COP score underestimates the severity of pneumonia in tropical northern Australia, but can be improved by using locally relevant additions.1 The authors’ revised scoring system, SMARTACOP, increased the score for an albumin level < 35 g/L and added Aboriginal or Torres Strait Islander status as a variable. While these additions are useful, the reason for adding ethnicity was not fully clarified. A factor overlooked was low serum 25-hydroxyvitamin D [25(OH)D] levels among dark-skinned Australians.2 Smoking, identified as a marginally insignificant risk factor,1 is also associated with lower serum 25(OH)D levels.3 Vitamin D enhances the innate immune system through induction by 1,25-dihydroxyvitamin D of cathelicidin and defensins, which combat several types of bacterial and viral infections including upper respiratory tract infections.4 In the 1918–1919 influenza pandemic in the United States, many deaths were due to pneumonia that occurred as a complication of influenza infection. An ecological study found that indices for levels of vitamin D production from solar ultraviolet-B irradiance explained 50% of the variance in pandemic case-fatality rates among 12 communities.5 The mechanisms proposed for the beneficial effect of vitamin D were reduced proinflammatory cytokine production, which would reduce damage to the epithelial lining of the lungs, and induction of cathelicidin and defensins to fight the secondary bacterial pneumonia infection. If sera are available for those included in the Australian SMART-COP study,1 they could be analysed for 25(OH)D levels to test this hypothesis.

William B Grant

In reply: We thank Grant for his interest in our study on pneumonia severity assessment in tropical Australia. Our revised scoring system included increased weighting for hypoalbuminaemia, as well as adding a point for Indigenous status, because these two factors had the strongest association with the need for intensive respiratory or vasopressor support on univariate analysis.1 Unlike vitamin D status, these and the other factors included in the scoring system are readily available measures that can be used in the clinical setting to rapidly predict the need for intensive support. The scoring system was not intended to identify underlying aetiology or risk factors for severe pneumonia. For example, Indigenous status is likely to be a surrogate measure for undiagnosed comorbidities, lack of access to health care, and socioeconomic disadvantage. We agree that vitamin D is important in immune function and that the levels of insufficiency that result in impaired resistance to infection are not well defined.2 Most data on vitamin D deficiency in dark-skinned populations in Australia come from temperate areas,3,4 and the reference offered by Grant to support the concern about vitamin D deficiency does not cite any data from Australian populations north of southern Queensland.5 Further studies are needed on the prevalence of vitamin D deficiency in Indigenous Australians in tropical areas, and the additional contribution of vitamin D deficiency independent of known risk factors of severity and outcome.

Joshua S Davis · Allen C Cheng · Bart J Currie · Nicholas M Anstey

To the Editor: Newby and Robertson’s study of the effect of computerised prescribing on the frequency of repeat prescriptions for antibiotics is important in highlighting unnecessary repeat prescribing.1 However, their work has highlighted another issue — researchers’ growing habit of using the prescription of selected antibiotics to infer indication, and then to measure appropriateness of care. When using the term “upper respiratory tract infections” (URTIs), do the authors mean viral infections or all URTIs, including bacterial infections? They state: While we did not include data on the indication for treatment in our study, the antibiotics we chose are those commonly used for respiratory tract infections. Therefore, the continued high rate of repeat ordering for these antibiotics remains a concern.1 We support the latter statement wholeheartedly, but the inference that the antibiotics examined in the study were used to manage URTIs (because these antibiotics are “commonly used to treat URTIs”) is inappropriate and incorrect. A media report misguidedly described Newby and Robertson’s study as examining “how GPs’ use of computerised prescribing systems affects antibiotic prescribing for upper respiratory tract infection.”2 The study was not about prescribing of antibiotics for URTIs, but this implication is apparent in their article. From the national Bettering the Evaluation and Care of Health (BEACH) program 2006–2009,3 we examined 20 011 general practitioner prescriptions for Newby and Robertson’s selected antibiotics: amoxycillin, amoxycillin/clavulanate, roxithromycin, and cefaclor. We would usually include cephalexin, because it is prescribed as often as cefaclor for URTIs at BEACH encounters, but we have limited our comparison to the above four antibiotics. In the BEACH program, GPs link the prescription to the problem being managed so we can determine the indication for which these antibiotics have been prescribed. Over the 3-year period of the 2006–2009 BEACH program, only 21.1% of these antibiotics were prescribed for URTIs (adults [≥ 15 years], 20.6%; children [0–14 years], 22.7%). In four out of five cases, the prescriptions were for acute bronchitis, sinusitis, acute otitis media or myringitis, tonsillitis, urinary tract infections, skin infections, pneumonia, and a variety of systemic infections. It cannot be assumed that a URTI is the indication simply because these antibiotics are most commonly used for its management, and by inference, that GPs are prescribing inappropriately. Newby and Robertson are not alone — the 2010 Productivity Commission report used the number of prescriptions for “antibiotics most commonly used to treat URTI” as one indicator of the appropriateness of GP services.4 These antibiotics are, in most cases, prescribed for indications other than URTI. The appropriateness of this prescribing cannot be assessed without knowledge of the indication, and without clear guidelines as to what level of antibiotic prescribing for each indication is “best” quality.

Joan V Henderson · Christopher M Harrison · Helena C Britt

In reply: We accept the evidence presented by Henderson and colleagues that the antibiotics examined in our study are not used exclusively for upper respiratory tract infections (URTIs), and we acknowledge in our article the lack of information on indication for treatment. However, data from the Bettering the Evaluation and Care of Health (BEACH) program have been used by others to suggest that the four antibiotics represent over 60% of the prescribed antibiotics for URTIs.1 Our study does not assess the appropriateness of the antibiotic choices, focusing instead on duration of therapy as implied by the issuing of repeat prescriptions. Irrespective of indications for use of these antibiotics, our data still support our primary conclusion that computerised prescribing is associated with increased repeat ordering for these, and probably other, antibiotics. The increase in repeat ordering could possibly be explained if doctors who use computers to prescribe see “sicker” patients or a significantly different case-mix from those who write prescriptions by hand. However, the size of the difference (70% v 40% of prescriptions with repeats, respectively), the consistency across the antibiotics examined, and the identical rate of repeat ordering on handwritten prescriptions in both surveys, makes this conclusion unlikely.

David A Newby · Jane Robertson

A 79-year-old woman was admitted with shortness of breath that had worsened over the previous week. Two months earlier, she had developed dysphagia with nocturnal regurgitation, cough and occasional stridor. Physical examination showed no abnormalities apart from an oxygen saturation level of 85% on room air. The patient had a history of achalasia, which had been treated 5 years earlier with pneumatic dilation. A chest computed tomography scan showed a severely dilated and tortuous oesophagus with retained food (Figure, A) causing compression of the trachea (Figure, B). The woman was successfully treated with laparoscopic Heller myotomy and discharged.

Nicola Mumoli MD

Incorrect figure: In “Early evidence for direct and indirect effects of the infant rotavirus vaccine program in Queensland” in the 3 August 2009 issue of the Journal (Med J Aust 2009; 191: 157-160), there was an error in Box 1 (Lambert et al). Under “(a) Notifications”, the values for the 5–19-years and 20–64-years age groups should have been reversed. Box 1, with the corrected figure, is reproduced here. 1 Percentage change in rotavirus notifications, tests performed* and tests positive* after introduction of a publicly funded infant rotavirus vaccination program in Queensland in July 2007 * Testing performed by Queensland Health Clinical and Statewide Services. † Percentage change in the number of rotavirus notifications in 2007 and 2008 compared with the number in 2006. ‡ Percentage change in the number of rotavirus tests performed in 2007 and 2008 compared with mean annual age group-specific values from 2000 to 2006. § Percentage change in the proportion of tests positive for rotavirus in 2007 and 2008 compared with age group-specific values from 2000 to 2006.

Stephen B Lambert · Cassandra E Faux · Lisa Hall · Frances A Birrell · Karen V Peterson · Christine E Selvey · Theo P Sloots · Michael D Nissen · Keith Grimwood

Older road users. Myths and realities, a guide for medical and legal professionals. Morris S Odell, Editor. Tucson, Ariz: Lawyers & Judges Publishing Company, Inc, 2009 (xvi + 302 pp). ISBN 978 1 933264 70 7. Traffic medicine is an emerging discipline, so not many resources are available on the subject. The fact that the editor of this book, Morris Odell — a Forensic Physician at the Victorian Institute of Forensic Medicine in Melbourne — is also my former teacher for whom I have great respect, made me read it with added interest. The proportion of elderly drivers is expected to rise significantly in the next 50 years and the role of medical practitioners in assessing their medical fitness to drive will increase. At present, there are no strict guidelines for assessing elderly drivers’ medical fitness to drive since, in many instances, the evidence available is contradictory. This book acknowledges the limitations of the assessment process, but provides abundant information to help readers form their own opinions. I found this approach to be unbiased, unintrusive and fair. The book was commissioned by VicRoads, in response to the 2003 Inquiry into Road Safety for Older Road Users by the Victorian Parliament Road Safety Committee. It addresses the main factors that affect driving skills — vision, cognition and motor function, with particularly interesting chapters on the effects of prescription drugs, and respiratory and sleep disorders. In addition, it examines different patterns of road injuries and the distinct crash epidemiology of elderly drivers. Odell has assembled a stellar team of contributing authors and the information provided is contemporary, easy to understand and backed up by evidence. The assessment options and principles of the assessment process of elderly drivers are explored in detail but the book stops short of recommending a particular assessment tool. Furthermore, it does not take a preferred position or make recommendations for when the elderly should not drive. This omission could be compensated by grabbing a copy of Austroad’s Assessing fitness to drive 2003, which gives strict recommendations for when people should not be driving. Apart from these small omissions, this is a great reference that gave me a lot of answers to questions that I haven’t been able to find for years. It will benefit medical and legal professionals whose work involves elderly drivers, as well as students and young doctors who would like to learn more about the relationship between different medical conditions and their impact on driving safety.

Ilian Kamenoff

Hype or hope? Although cancer receives a great deal of attention in the media, little is known about the main messages conveyed to readers. A content analysis of over 400 recent articles about cancer in several major US mainstream publications found that while more than half discussed “aggressive” treatments, 30% reported associated adverse effects and only 13% mentioned that these treatments can fail. End-of-life issues were rarely discussed, appearing in only 2.5% of articles. The most common articles were about breast or prostate cancer. The authors concluded that media portrayal of cancer may be inappropriately optimistic as, overall, about half of all cancer patients are known to eventually die from their disease or related complications. Arch Intern Med 2010; 170: 515-518 doi:10.1001/archintermed.2010.11 Donor survival According to results of a study in the United States, live kidney donors appear to survive as well as non-donors — in the longer term. Among a cohort of about 80 000 live kidney donors followed for a median of 6.3 years, survival was similar to that of a matched cohort of non-donors from one year after nephrectomy. However, during the 90-day postoperative period, there was a total of 25 deaths (equivalent to a mortality rate of 3.1 per 10 000) in the donor group; notably lower than the reported surgical mortality rate of about 18 per 10 000 for laparoscopic cholecystectomy and about 260 per 10 000 for non-donor nephrectomy. Surgical mortality was higher in male donors (RR 3.0, 95% CI 1.3−6.9) and in those with hypertension (RR 27.4, 95% CI 5−149.5), indicating the importance of appropriate donor selection. JAMA 2010; 303: 959-966 doi:10.1001/jama.2010.237 Poker face Can people tell what you are thinking by your eye movements? Melbourne researchers have put this to the test by assessing how often they were able to accurately predict the magnitude of a random number “thought of” by 12 test subjects, before they had actually spoken it. Working on the basis of the already recognised “mental number line” — that is, that looking up and to the right is usually associated with a larger number and down and to the left with a smaller number — they were able to predict the direction and magnitude of the next number correctly about 60% of the time (P< 0.001). The study authors state that “the eyes may not only reveal what is in a person’s mind, but also illustrate how abstract thoughts are grounded in basic sensory-neural processes.” Curr Biol 2010; 20: R264-R265 Motherhood and suicide risk In 1897, Durkheim hypothesised that parenthood conferred a protective effect against suicide. Now, more than 100 years later, a cohort study of more than 1 million Taiwanese women has found evidence in support of this hypothesis: having more than one child appears to lower suicide risk in mothers. Further, this apparent protective effect is more evident with increasing parity. The women were followed up for at least 20 years after a first live birth between 1978 and 1987. After adjusting for age, years of schooling and marital status, the estimated hazard ratio for suicide was 0.61 among women with two live births and 0.40 among those with three or more live births. While it is difficult to assume a direct cause-and-effect relationship, the researchers proposed factors such as increased self-worth, based on the mother’s perception of being needed, and enhanced social networks as possible explanations for this observation. CMAJ 2010 doi:10.1503/cmaj.090813 Diabetes burden Which country bears the highest diabetes-related disease burden? It may well be China. A large study involving glucose-tolerance testing of more than 46 000 adults in China has shown that about one in 10 have diabetes, while about 15% have pre-diabetes. This equates to about 50 million men and 42 million women in China with diabetes. Estimated prevalence increased with age, reaching about 1 in 5 among those aged over 60 years. Diabetes was more prevalent in urban than rural residents (11.4% vs 8.2%), and this was thought to be related to rapid changes in lifestyle factors such as diet and physical activity. However, the more troublesome finding was that in about 6 of every 10 cases, the diabetes was undiagnosed. N Engl J Med 362; 12: 1090-1100.

Alison Williams