Volume 196 Issue 1

Highest quality research, faster publication and easier access Einstein noted that we go beyond our limits once we recognise what they are. At the MJA, we recognised that we could go further as a journal of scientific record in this country and as a means of communication within the medical profession, and this led to a year of change in 2011. Revitalising internal processes for the handling of research manuscripts, developing new content and relaunching the print journal were the key changes. In 2012, there will also be considerable development, much of it focused on changes in our web-based platform. Our new website, soon to be launched, is benchmarked against industry (not medical journal) standards and will feature markedly improved functionality, including ease of login (we have heard you!) and a world-class search function that is fast and discerning. It will offer increased capacity for timely publishing of research and educational content (including rapid online publication and publication ahead of print). In the print journal, this will allow more logical grouping of related material and topics. The MJA is primarily a vehicle for the dissemination of high-quality medical research and information, and it is differentiated from other publications by this focus, by detailed peer review of submissions, by the active involvement of an experienced team of medical editors and by a stringent and careful editing process that is free from commercial influence. We highly value good research, and we are keen to nurture our position as Australia’s premier general medical journal and to further improve the dissemination of research to benefit researchers, clinicians and patients. To this end, we have revised our access policy to make all research articles freely available online, with full and continuing open access from the time they are first posted online. In 2011, a record number of submissions allowed us to be more selective in what we published and to focus on material of higher quality — an important benefit for readers. For authors, we reduced the time taken to reach a decision about publication through our new manuscript handling processes. In conjunction with our new open-access policy for research articles, this means important research findings will be published faster and be immediately available to an unlimited national and international audience. We are planning to launch MJA Open for other material, such as individual research articles or clusters of articles on specific topics, similar to our previous Supplements. New content was a significant feature of the MJA in 2011 — for example, our Practical Neurology series, which has been very well received. As doctors, we don’t lack information, but what we really need is relevant information that we can trust. Little in the medical press is as thoroughly researched and reviewed, and as meticulously cross-checked, as the MJA’s clinical series. Later this year, we will be publishing further series on medical education and ethics, with more in the pipeline. We plan to cluster Journal content throughout the year, and to work closely with the various Colleges to offer publication of important research to coincide with its presentation at major conferences. An expanded web presence will also offer the ability to present material in new ways. We will be able to receive and post your comments, to allow immediate debate of important issues. We are also keen to utilise the multimedia capability of the new website and we will provide peer review for multimedia material, just as we do for written material. We want to expand the role of the MJA as a provider of medical education, and we see an increasing need for recognition of the work of good medical educators. While researchers are able to gather citations for excellent research, educators have difficulty proving their worth in the same way. To this end, we will offer the option of submitting educational material, including tutorials and lectures, in a multimedia format for posting on the MJA website. Presentations will be peer reviewed before acceptance and, once posted, will be accompanied by a précis in the MJA, so that the presenter’s work is citable. Our goal is to provide an inclusive, interactive forum for the best medical information and research in this country. Changes in the MJA are all designed to meet this goal, each establishing a platform for further development. As Einstein emphasised, all effective change begins with knowing who you are. The MJA is Australia’s premier general medical journal, and our aim is to be your preferred choice for medical information and communication.

Annette Katelaris MB BS, MPH, FRACGP

The first Australian report is welcome and should help inform policy Traumatic brain injury (TBI) continues to be a significant public health issue in Australia. Despite advances in acute medical care and decreases in mortality, those affected experience long-term morbidity and have an increased late mortality rate. TBI is the leading cause of death and disability among young people, and the incidence of severe TBI is higher in men than women at a ratio of 3.5 : 1.1 The leading causes of TBI include: motor vehicle accidents (50%); falls (21%); violence (12%); and sports and recreation (10%).2 In Australia in 2008, there were 2493 new cases of TBI (about 1000 of these were severe),2 and the estimated total cost of care was $8.6 billion. Across Australia, lifetime cost per incident case of severe TBI was estimated at $4.8 million.2 In 2007, more than 16 000 patients were admitted to hospitals with TBI,3 with an average length of stay of 6.1 days in acute care, 64.2 days in rehabilitation and 84.1 days in other care. These patients characteristically have multiple disabilities and, in addition to health care services, they frequently receive other disability support services (eg, case management, individual therapy support, life skills development). Many factors affecting outcomes after TBI are modifiable, and influenced by medical management. Multidisciplinary assessments early in the course of the disease guide medical care and provide predictive information about the potential for recovery. Rehabilitation interventions have documented benefit in patients with TBI.4 Research into rehabilitation in severe TBI is challenging because of: the heterogenous manifestations of sequelae of severe TBI; the unpredictable course of the disease; the range and variety of rehabilitation services; and inconsistent use of appropriate outcome measures.4 Few studies tackle long-term outcomes in this population, so evidence is insufficient for establishing optimum integrated care, agreement on a minimum clinical dataset for effective communication between clinicians, and incorporation of patient and caregiver perspectives. The multicentre study by Baguley and colleagues in this issue of the Journal5 adds clarity by describing the long-term mortality pattern in adults with severe TBI, and identifies the risk factors associated with mortality. Among their 2545 patients with severe TBI discharged from tertiary rehabilitation units of the New South Wales Brain Injury Rehabilitation Program, with a mean follow-up period of 10 years, there were 258 recorded deaths. The authors report an increased risk of death up to 8 years after discharge from rehabilitation services that was 3.2 times greater than that for the general population, and higher than rates in previous reports (range of long-term mortality estimates, 1.1–3.1).6 The mortality rates remained higher than for the general population for up to 5 years after discharge from rehabilitation. True mortality rates may be underestimated; similar data for late mortality after TBI in children and Indigenous people are needed. The findings of Baguley and colleagues have implications for health service use and health modelling. The study by Baguley et al is the first long-term mortality report of Australian data, and shows an increased risk of death among patients with more severe TBI, greater functional dependence, previous drug and alcohol misuse, epilepsy before their TBI and older age at injury; these findings are consistent with those of other studies.7,8 Compared with the general population, those with severe TBI had a particularly high risk of death from respiratory disorders, and a high risk of death from nervous system, mental and behavioural, and digestive disorders. Discharge to an aged care facility was identified as a risk factor independent of functional dependency at discharge from rehabilitation, and needs further investigation. Older patients are considered at risk because of an altered pathophysiological response in the ageing central nervous system. Further, health, lifestyle and social deprivation have been linked with survival.9 Other reports suggest that TBI itself provokes lifestyle and behavioural changes, or defines a subgroup in the population at higher risk of death for other reasons.7 Future research should target interventions for general preventive measures to maintain health, and social and lifestyle changes in people discharged to the community after a TBI.7 The important elements of service provision for patients with TBI are similar to those in other conditions requiring neurorehabilitation:10 involvement and support of primary health practitioners; education of doctors, patients and caregivers about mortality, declining health and high-risk behaviours for targeted intervention; clinical guidelines to include routine postdischarge follow-up over a longer time, and a flexible health care delivery system that prioritises the rehabilitation needs of patients with TBI; and a clear plan of action and compliance, including indications for referral to specialised multidisciplinary services. Policy recommendations to establish services for continuity of care (acute to subacute and community care) for patients with TBI include:4,10,11 develop rehabilitation services (including infrastructure and personnel) for patients with severe TBI; provide services to meet the complex needs of those with severe TBI, to identify unmet needs for assistance and reduce reliance on informal assistance; link TBI rehabilitation programs with the existing Australian Rehabilitation Outcomes Centre dataset for long-term collection of clinical data, using standardised common data elements; computerise national monitoring systems in real-time to document mortality and morbidity in TBI, and monitor patterns of recovery; review policy and implement rigorous assessment of the impact of quality care to decrease mortality rates and harm from ineffective or insufficient treatment; expand national insurance schemes to fund non-compensatable TBI rehabilitation; and maintain a sustained public health information campaign to publicise issues and promote strategies for implementation in patients with TBI.

Fary Khan MB BS, MD, FAFRM

Health professionals should educate families about risk factors for accidental asphyxiation in shared-sleeping arrangements Over the past two decades, great advances have been made in identification of hazardous sleeping environments for infants and young children, with significant reductions in numbers of deaths.1 However, one issue that continues to incite heated debate is whether adult caregivers should sleep on the same surface as infants,2 referred to as “shared sleeping”. It is recognised that infants who sleep in the same room as their carers have a reduced risk of sudden infant death syndrome (SIDS),3 possibly due to an increased level of direct supervision.4 However, what of infants who sleep in the same bed as their parents or carers? First, it is important to clarify terminology. Although it is claimed that shared sleeping increases the risk of SIDS, it is perhaps more accurate to state that it is associated with an increased risk of infant death generally. An indication that shared-sleeping deaths may be different to “classical” SIDS deaths that occur among infants sleeping on their own is a finding of an almost equal sex ratio in shared-sleeping deaths, compared with the 2 : 1 male–female ratio among infants who died of SIDS.5 If some of the risk factors for shared-sleeping death (eg, parental obesity, fatigue, soft sleeping surfaces) are examined in isolation, accidental suffocation appears to be a more likely mechanism of death than subtle processes leading to SIDS.5 These apply to any shared-sleeping surface, not just to beds. It is difficult to formulate absolute recommendations on shared sleeping, as the current incidence in most communities is unknown, and the form that it takes varies greatly between families. There are also cultural issues to take into consideration — for example, shared sleeping is very common in South-East Asian communities, but with low incidences of unexpected infant deaths.6 However, a study from Avon, United Kingdom, found a disturbing percentage increase in shared-sleeping deaths among two cohorts of infants who died of “SIDS”, from 12% (17/147 in 1984–1988) to 50% (18/36 in 1999–2003) (P < 0.001).7 The authors noted that although the number of shared-sleeping deaths that were not on sofas dropped (from 16 to 14), the decrease was not as great as that among infants who were sleeping on their own, perhaps explaining the increased proportion of unexplained infant deaths found in shared-sleeping situations. This difference may be due to mechanisms of death being different in the two circumstances. A similar effect was noted in South Australia, where the proportion of shared-sleeping deaths increased from 7.5% of “SIDS” deaths (23/306 in 1983–1990) to 32.3% (21/65 in 1991–1993).8 The percentage of deaths in shared-sleeping situations in the early part of the study also showed an overrepresentation compared with the shared-sleeping rate of 1.5% in the general community in 1988.8 As some infants are particularly vulnerable to the effects of airway occlusion,9 and as there is often no clinical predictor of this vulnerability, all that can be stated is that certain infants may be inherently at increased risk in a shared-sleeping situation. It is generally agreed that in Western cultures, the safest place for an infant is in a cot that meets recommended safety features and is positioned beside the caregiver’s bed.1,2 Supporters of shared sleeping cite advantages that include an increased incidence and longer duration of breastfeeding, enhanced maternal–infant bonding and improved settling.1 However, it has been reported that 50% or more of infants who are found unexpectedly dead are sleeping with an adult.10 The suggestion of possible accidental asphyxia by a parent “overlaying” a shared-sleeping child has been criticised, because it has been assumed that a parent would always arouse. However, parents can fail to wake if they are sedated or overly fatigued. There is an increased risk of infant death when caregivers have taken illicit drugs, smoked, or consumed more than two units of alcohol.10 In addition, it is not necessary for an adult to be lying over an infant completely for respiration to be compromised, as an infant who has rolled into a trough between a parent’s much larger body and a soft mattress may also be at risk.11 This is exemplified by the dangers of shared sleeping on a sofa.7 On occasion, parents state that they successfully slept in the same bed as all of their children without any deaths occurring. While such anecdotes are undoubtedly true, few risks are absolute and so it cannot be used as definitive evidence that shared sleeping is always a safe practice. The key to assisting with this issue lies in adequately informing caregivers of potential risks. Clinicians should discuss with caregivers the risk factors for accidental asphyxiation in shared-sleeping arrangements, such as sedation, excessive fatigue and hazards predisposing to suffocation. This may help prevent infant deaths in the future.

Roger W Byard MB BS, MD

The full content of this article is available by downloading the PDF.

The full content of this article is available by downloading the PDF.

Ray Moynihan explores the push for new powers and strong opposition to it If there was ever a case of market forces running ahead of regulators, it is corporatised medicine in Australia. Driven by medical entrepreneurs and merchant banks, the creation of giant health care empires has taken place with little public debate or political interest. While a new private industry is now successfully profiting from publicly funded Medicare, health authorities have so far found no meaningful mechanism to police the sector. “The business of medicine has been altered forever”, argues the former head of Medicare’s watchdog unit, “by the entry of corporatised medicine”.1 Testifying to a recent senate inquiry, Tony Webber, former Director of the Professional Services Review (PSR), said he’d like to see a revamped PSR scheme within Medicare given the power to “investigate scams and unacceptable corporate behaviour, of which I have seen significant examples”. Asked if any executive had been prosecuted, Webber told senators: “Sadly, no, because the legislation makes it very difficult to do so”.1 Responding to his concerns, the committee recommended strengthening the watchdog’s powers and government is currently considering its response. Evidence of corporate “scams”, says Webber, remains largely anecdotal and based on tip-offs which, while appearing credible, are currently unable to be followed-up. According to Webber, the problem is while companies are geared to make money, Medicare was never designed to pay the doctor and a nice corporate dividend as well — a theme he expands on elsewhere.2 One of the industry’s giants is Sonic Healthcare, owner of the Independent Practitioner Network with 140 medical centres and around 1000 GPs who produced “strong revenue growth” last year, contributing to Sonic’s overall profit of $295 million.3 The other giant is Primary Health Care Limited, running almost 90 centres, also contracting 1000 doctors, worth around $1.5 billion, and with profits of $80 million.4 Another player is Healthscope, bought recently by a consortium of global private equity firms. All three are “vertically integrated”, with medical centres, pathology laboratories and imaging facilities. There is no suggestion that these, or other particular corporations, or people associated with them, engage in or encourage any form of inappropriate behaviour. The man known for pioneering corporatisation of health care in Australia is Edmund Bateman, managing director of Primary Health Care Limited. The company describes itself as the “most profitable in this field” with a “formula” offering value to doctors and patients.4 In an extended interview with me recently, Bateman strongly rejected the need for enhanced watchdog powers, saying it was “based on the assumption that the corporation is responsible for the behaviour of the doctor”, which was “out of touch” with the reality. He said there’s also an assumption of “improper pressure” on doctors, but it doesn’t exist. “I can’t tell them what to do”, he told me, “if there is any pressure, it’s to practise better medicine”. While stressing that doctors signing contracts with Primary Health Care Limited retained clinical autonomy, in general, they also “undertake to support our services, where clinically appropriate” he said, adding doctors “tend to support the pathology in the building, out of convenience”. The idea of forcing corporations to contribute to paying the fines of doctors found to have practised inappropriately is also opposed by Bateman: “it’s human nature for people to try and blame other parties”, he says, “professionals in particular are responsible for their own behaviour”. Arguing it’s not “proper process”, he suggests that the entire PSR Scheme should be abandoned and any action against doctors happen via “normal legal process”. Asked about his own use of courts to take action against doctors contracted to his companies, and a newspaper report that there had been dozens of cases against practitioners in the past decade,5 Bateman declined to confirm a figure, saying that of the 1000 contracts with doctors only a “very small minority” ended in litigation, and that he is suing the newspaper involved. Questioned about suggestions that his centres had created and billed for “care plans” for patients who regularly saw doctors outside, he said that “sounds like sour grapes from someone who should have provided one before this”. Other corporate chiefs contacted declined to comment. In my view, one way to independently assess competing claims about corporate medicine might be to compare profiles of doctors working inside and outside corporate structures. While complex, with confounding factors, a sophisticated analysis could cast much-needed light here and build academic expertise in the field. As to recommendations for new powers to “pursue abuse” of the system,1 the government’s response is pending. Perhaps it may also be timely to reassess just how well the private-for-profit corporate structure sits with the spirit of a publicly funded universal health insurance scheme.

Ray Moynihan BA

Yes. Public health adviser David Roder and Cancer Council Australia CEO Ian Olver believe the reduction in breast cancer mortality in Australia reflects both treatment and screening effects All screening programs should be assessed for their benefits and risks, including the extent of overdiagnosis. Recently, Burton and colleagues concluded that almost 60% of the Australian decline in breast cancer mortality since 1991 could not be due to BreastScreen Australia (the free national mammographic program), attributing most of the decline to adjuvant hormonal and chemotherapy.1 Questions around attribution are not new. There has been no formal modelling in Australia, but modelling funded by the National Cancer Institute in the United States suggested that about half the US breast cancer mortality reduction may be due to adjuvant therapy and about half to screening.2 Age-standardised breast cancer mortality rates have decreased by about 29% among Australian women since the 1989–1991 period, when organised mammography screening (now known as BreastScreen) began.3 Compared with a linear projection of mortality increases in the 1980s, the observed rate in 2007 was about 38% lower.3 Observations on women outside the screening age range show that factors other than screening would have contributed to this decline, but there is also evidence for an important BreastScreen effect.3 Three evaluations of mammography screening of Australian women aged 50–69 years, including the formal BreastScreen Australia Evaluation Plan, indicated reductions in breast cancer mortality of between 30% and 47% from screening.3 This range is broadly consistent with trial evidence where a reduction of around 35% was estimated by an expert working group of the International Agency for Research on Cancer (IARC).4 A 25% reduction in breast cancer was estimated by Australian researchers from a meta-analysis of trial data for all ages.5 Collective results of 35 studies in other countries are similar to the IARC’s 35% reduction estimate,3,4 although individual study results varied from little or no benefit to reductions of up to 76%.3 With present participation rates in Australia’s BreastScreen program, a 35% reduction in breast cancer mortality in participants would correspond with an estimated 270 fewer breast cancer deaths a year in all Australian women aged 55–74 years. (Note that this allows for a time lag of 5 years in deaths.) Breast cancer incidence rates rose in Australia following the introduction of BreastScreen.3 The extent to which this reflected lead-time effects of screening, changes in pathology and other diagnostic practices, overdiagnosis, and real increases due to changes in underlying risk factors (eg, reproductive behaviour, body weight, alcohol consumption and use of hormone replacement therapy) is unknown. Increases in incidence were already occurring in the 1980s before BreastScreen introduction,3 but the contributions of increased use of private mammography and changes in risk factors during that period are not known. The increase in breast cancer mortality rates in the 1980s is suggestive of real increases in underlying incidence.3 There is concern that screening may result in detection of cancers that would never have caused symptoms or death in a woman’s lifetime (ie, overdiagnosis).3 There is no consensus on levels of overdiagnosis, with estimates worldwide varying from close to zero to over 30% of diagnosed cancers, irrespective of whether in-situ lesions were included.3 The estimates vary so widely that interpretation is difficult. Research is needed to better define levels of overdiagnosis and, ideally, to develop more effective means of determining at diagnosis the potential for screen-detected and other breast cancers to progress. In summary, it is likely that the reduction in breast cancer mortality in Australia reflects both treatment and screening effects. The relative contribution of each to the overall reduction is not clear, although there is evidence that both would be contributing substantially. Women should be informed of both the risks and the benefits of screening, including the uncertainty around overdiagnosis. However, present screening participation levels of 50–69-year-olds in BreastScreen would be consistent with a significant annual reduction in breast cancer mortality. Levels of overdiagnosis are uncertain and require better definition. Means of better predicting the likelihood of progression of untreated in-situ lesions and early invasive breast cancers to advanced disease are needed, and this need is likely to increase as more sensitive screening and diagnostic technologies are developed.

David M Roder PhD · Ian N Olver MD, PhD, FRACP

No. Breast cancer researchers Robin Bell and Robert Burton believe that screening can result in overdiagnosis Screening mammography undoubtedly saves lives. Since 1991, when Australia’s free national mammographic screening program (BreastScreen Australia) began, there has been a 29% reduction in breast cancer-specific mortality. However, our analysis of age-stratified data indicates that BreastScreen does not account for most of this mortality reduction.1 Furthermore, it is now recognised that the balance between the benefits and harms of screening has become increasingly unfavourable. Women should be given a balanced explanation of what BreastScreen offers them. Our study analysed age-specific trends in breast cancer incidence, mortality and BreastScreen participation by Australian women aged 40–79 years since 1991.1 We found that the participation rates and relative mortality declines were the opposite of what the randomised controlled trials (RCTs) of mammographic screening had predicted. Women aged 40–49 years, who had the lowest BreastScreen participation (about 20%), had the largest mortality reduction (43.6%; 95% CI, 34.8%–51.2%). Women aged 60–69 years, who had the highest BreastScreen participation (about 60%), had the smallest mortality reduction (19.1%; 95% CI, 10.5%–26.9%). We also analysed the proportions of the declines in absolute breast cancer-specific mortality from 1991 to 2007 in two parts (before and after 1999–2000), to identify periods before and after any effect of BreastScreen on mortality might have been expected. We found that only about a third of the reduction in mortality in the age group invited for screening (50–69 years) occurred after 1999–2000.1 We have calculated the contribution that adjuvant endocrine therapy and chemotherapy could have made to the reduction in breast cancer mortality in Australia since 1991. Australia is unique in having six datasets from population-based breast cancer treatment surveys between 1986 and 1999. These document the stage at diagnosis and adjuvant treatment received for early breast cancer for different samples of Australian women. Based on a 10–15-year follow-up of their overviews of RCTs of adjuvant therapy in early breast cancer between 1985 and 2000, the Early Breast Cancer Trialists Collaborative Group (EBCTCG) concluded that appropriate use of anthracycline-based chemotherapy followed by tamoxifen for oestrogen-receptor-positive disease would result in annual breast cancer mortality reductions of 57% for oestrogen-receptor-positive women < 50 years of age and 45% for those aged 50–69 years.2 Our analysis, using 1999 Victorian survey results and the EBCTCG overview, found that breast cancer mortality reductions in Australian women in 1999 from adjuvant endocrine therapy and chemotherapy could have been up to 38% for women aged 40–49 years, and up to 24% for women aged ≥ 50 years.1 Therefore, adjuvant therapy had the potential to produce most of the 29% reduction in breast cancer mortality in Australia since 1991. In theory, screening for an asymptomatic earlier stage of a disease that is more effectively treated with available therapies than symptomatic disease will produce less morbidity and mortality, but screening can result in overdiagnosis. Overdiagnosed breast cancers are those detected by screening mammography that would not have become symptomatic in the woman’s lifetime. Overdiagnosis by mammographic screening is most accurately estimated from the RCTs by comparing the increased numbers of breast cancers diagnosed in women invited to undergo screening compared with those not invited. A recent Cochrane systematic review of the RCTs puts the estimate at 30%.3 An estimate from incidence trends in New South Wales indicated that 30%–40% of invasive breast cancers were overdiagnosed in 1999–2001.4 The benefits and harms of mammographic screening are measured in terms of the ratio of lives saved to cases overdiagnosed. Using the RCT data, the 2011 Cochrane review determined that, with 30% overdiagnosis and a relative mortality reduction of 15%, “for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and treated unnecessarily”.3 As the outcome of treatment for both symptomatic and asymptomatic disease improves, the impact of screening diminishes and the balance of benefits to harms will become less favourable. This has serious implications for health policymakers. We believe it is time for women to be presented with a more balanced view about the benefits and harms of breast screening. Screening programs are currently undergoing review in the United Kingdom, and one of the first commitments is to a new process of developing written information for the public that will synthesise information on benefits and harms. There has been an assurance that the leaflet about breast cancer screening will be among the first to be revised.5

Robin J Bell PhD, MPH, FAFPHM · Robert C Burton MD, PhD, FRACS

Lack of audit control and inability to adapt to change leads to massive waste As Director of Professional Services Review (a role established to protect the integrity of Medicare and the Pharmaceutical Benefits Scheme) for over 6 years, I gained an insider’s insight into how dysfunctional the Medicare/Medibank Scheme has become since the Health Insurance Act 1973 (Cwlth) was introduced. The then Minister for Health, the Hon. Bill Hayden, stated in his second reading speech that the purpose of the scheme was to create the “most equitable and efficient means of providing health insurance coverage for all Australians”.1 The universality of medical insurance coverage benefited all Australians, particularly those for whom a doctor’s visit represented a significant proportion of income. From the beginning, there were inadequate safeguards in a scheme based on the honour system. In no other area of public expenditure where recipients have significant control has so little attention been paid to audit. Medicare Australia administers over half a billion transactions every year for the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Medicare is very efficient at its core business — that of distributing benefits. Electronic claiming has addressed criticism of earlier inefficiencies. However, Medicare’s ability to ensure benefits have been paid appropriately has never fully coped with the medical business environment. Extrapolating modestly from the misuse of the MBS, PBS and the Medicare Safety Net (financial assistance for high out-of-pocket costs for out-of-hospital MBS services) that I am directly aware of, I estimate that 2–3 billion dollars are spent inappropriately each year. Unfortunately, there are no attempts to quantify these losses more accurately. The reasons for this leakage are diverse. The MBS is riddled with misdirected incentives for practitioners, contains items that have not been reviewed despite advances in technology, and has many examples of good public policy thwarted by the MBS rules. In general practice, general practice management plans (GPMPs) and team care arrangements (TCAs) have created opportunities for a bonanza for some practices. Several practitioners I have reported on had admitted that their corporate owner had a business plan based on a defined number of these items claimed every week, irrespective of clinical need. Medicare Australia is also aware that a significant proportion of these plans are not carried out by a patient’s usual doctor’s practice.2 Anecdotally, claiming for clinically unnecessary GPMPs is significant throughout Australia. The policy intent of GPMPs was to provide a higher standard of care for patients with complicated chronic disease. While many doctors use these items appropriately for positive patient outcomes, a proportion of claimed items have added nothing materially to patient care. The TCA items are based on a model of care that works well in an inpatient setting, but does not translate to general practice. This item has created a whole industry of allied health practitioners and dentists who, through a TCA, draw on the public purse. Under a TCA, there is incentive for doctors to be pressured to provide the paperwork for “free” podiatry, physiotherapy, psychology, and dental care, facilitated by computer systems that can generate the necessary paperwork in minutes. The MBS rebate for a GPMP is $138.75, and for a TCA is $109.95. The policy intention was to allow patients with chronic or terminal disease to receive previously unaffordable care, but has created perverse incentives for all parties involved. This is bleeding several hundred million dollars per year as the policy intention is buried by inappropriate claims. The approach of the Department of Health and Ageing (DoHA) in not allowing discretion to doctors to refer purely on clinical grounds has led to this situation. The policy intent by government was sound. However, the DoHA developed MBS items that create incentives to easily misuse and work around the MBS requirements, leading to their misuse by a proportion of both medical and allied health practitioners. Some practitioners consciously misuse the MBS occasionally, and some do so regularly. The policy intent could have been achieved by allowing direct referral, without financial incentive to the doctor. This measure alone would have saved the health budget well over a billion dollars over the life of the program. Instead, a monster was created, eroding the integrity of the health budget. Items are added to the MBS after a long and exhaustive process of evaluation. This includes consideration of the skill level involved, the cost of necessary equipment, time taken for a procedure, and the overall cost–benefit to the community. However, once items are on the MBS, as long as they are still being used, they are rarely re-evaluated, and they attract the yearly rise in benefit level. Minister Roxon, in her first term as Minister for Health, bravely tried to reduce ophthalmologists’ fees for cataract surgery by 50%.3 These items were introduced when the procedure was not considered routine, took much longer than today, and required an inpatient stay of more than a week. The benefit reflected this. In the nearly 40 years since, technology has moved on and now this surgery can be performed under local anaesthetic as a day-procedure lasting 20 minutes. Private patients are sometimes charged more than $4000 for this procedure. In the end, the Minister was only able to achieve a 12% reduction on the MBS fee.4 The top providers of this item have performed more than 20 procedures in one day, according to Medicare Australia data. Not bad work if you can get it, but very poor public policy! The same lack of rigour in reviewing items also applies to gastroenterology and cardiology. While most gastroenterologists and cardiologists practise ethically, there are a few practitioners whose repeated use of procedures and investigations is highly questionable in patients whose clinical condition appears not to warrant them. However, there is no one asking the questions. The Medicare Safety Net is one of the most poorly thought-through pieces of health legislation. Despite its laudable policy intent — to help those with severe and chronic disease afford the cost of modern medical care — its implementation has gaping holes. The open-ended nature of the Safety Net offers the minority of unscrupulous and greedy practitioners opportunities to exploit it. After the Safety Net was introduced, a small group of obstetricians raised their fees for antenatal care from around $3000 to nearly $10 000. Such use of the Safety Net was perfectly legal, thanks to sloppily drafted legislation. During my time as Director of Professional Services Review, the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for “designer vaginas” at $5000–$6000 each. I knew that the DoHA was aware of such misuses of the Safety Net. However, there seem to be no politicians with the appetite to face the problem and rein in millions of dollars in potentially inappropriate payments. Another major concern of mine has been the quantity of prescription drugs, particularly narcotics and benzodiazepines, finding their way onto the street. These drugs are well controlled by the manufacturer and the supply chain to the pharmacy. The weak link is the doctor’s prescription pad. Throughout my term as Director of Professional Services Review, I saw extreme examples of drug prescriptions that were clearly being misused or dispensed for resale by patients. In one instance, a doctor was prescribing 100 ampoules of 30 mg of morphine every week to a young patient without an appropriate indication. The state pharmaceutical branches are underresourced to track the prescription of benzodiazepines. Medicare is unable to identify abnormal prescribing patterns because many benzodiazepines are supplied on a private prescription. It is cheaper for a patient on a federal government benefit to pay for one private prescription for 200 diazepam tablets (less than $20) than to pay for four subsidised prescriptions of 50 tablets. I found many instances where a practitioner had supplied a PBS prescription for 50 tablets and a private prescription for 200 tablets.5 It is not only the MBS and the PBS where maladministration occurs. On several occasions I came across significant cost-shifting between the states and the federal government. Medicare was being used to subsidise state health budgets. Private radiology and pathology services were used for public inpatients, Medicare benefits were used to fund staff specialist study tours and to buy essential equipment. This is against the provisions in the Council of Australian Governments National Health Care Agreement. When this was pointed out to officers in the DoHA, I was told not to say anything. There is significant wastage within the Medicare scheme, which is threatening our ability to maintain first world standards in health care delivery. Australians are fortunate that, in the main, we do have a motivated and ethical health workforce. However, many of our colleagues feel let down by a system that so often does not deliver a timely or cost-effective service with proper controls. Many doctors I have spoken to are disillusioned by the inappropriate claiming and practice they are aware of. They feel disempowered to be able to effect change in our current health system.6 It is time for a thorough review of the manner in which health care is delivered in Australia. Piecemeal policy changes and bandaids are no longer adequate. To be of any value, a major review needs bipartisan political support. However, so long as health policy is used to bludgeon the other side of politics, we will never have meaningful change.

Tony D Webber MB BS, FRACGP

Lack of transparency and reliance on statistics alone make doctors vulnerable The Professional Services Review (PSR) was established to investigate and manage situations where the Medicare system was being used inappropriately by doctors. Undoubtedly, the PSR’s activities have identified and addressed instances of doctors knowingly exploiting Medicare. However, over the past 5 years, an initial general disquiet about the increased effect of the PSR’s investigative system and processes on general practice grew into widespread concern among broad sections of the medical profession and others. The PSR committees were disbanded because they were not ratified by the Australian Medical Association (AMA), 39 cases under review were dropped, and a senate inquiry into the entire running of the PSR scheme was conducted. The inquiry resulted in the publication of seven recommendations for improvements in the system,1 with a review with all relevant stakeholders planned for 12 months later. A common recurrent complaint was Medicare’s focus on statistics, with less emphasis on other information provided. Medicare targeted the right-hand end of the bell curve, assuming this was where inappropriate practice occurred. The “vanilla GP” who held four standard consultations an hour was the Medicare epitome of a gold standard practitioner and was safe from audit. However, the further GPs steered away from this “standard” practice, the more they were at risk of being investigated by the PSR. There is no substantial evidence that statistical outliers represent a high-risk group, and yet the PSR has intensified its auditing activities among such doctors, increasing auditing from 1% to 4%.2 Surveys of the medical profession have revealed deep concerns with the system and processes of the PSR. The AMA posed the question: “Do you think the Medicare audit process has become too heavy handed?”, to which 88% of respondents (307) voted yes.3 The Medical Observer ran a survey that attracted over 200 replies. It showed that over 80% of respondents felt that Medicare and the PSR had not replied adequately to queries on the Medicare Benefits Schedule and less than 15% felt confident they would pass an audit on the Enhanced Primary Care item numbers.4 The specific concerns held by us and others are numerous. In our view, the operational processes of the PSR and the Medicare audit system appear to be non-transparent, with too much power in the hands of the PSR Director. There is a denial of natural justice, with a high conviction rate and pressure to accept “negotiated agreements”, with no practical appeal process. Fines imposed are large, running to between five and six figures. Preserving patient confidentiality during an audit seems to disadvantage the case of the doctor being audited. The PSR does not appear to respond to concerns raised in these areas, and this undermines community confidence in primary care. A particular problem is that Medicare and the PSR give little or no guidance to GPs on the approved use of item numbers in the Medicare schedule. They have tried to refer complex requests back to the AMA and Royal Australian College of General Practitioners,5 and will not give binding interpretations on the use of Medicare items. Their past rulings do not provide useful guidance. This puts GPs in an extremely vulnerable situation, being unable to reliably check their interpretation of Medicare item numbers, yet able to be severely punished for actions judged to be misdemeanours at a later date. Some of the submissions to the Senate inquiry6 show the heavy-handedness of the PSR, particularly in relation to procedures performed by GPs. Examples include a rural GP being required to pay back a substantial sum because he had not personally documented the wound dressings and vaccinations performed (a nurse had done the documentation), and the rejection of independent assessment that disagreed with the PSR when investigating a rural GP for computed tomography scan orders. The PSR investigated 200 records associated with a procedural rural GP who had been in practice for 26 years because of “statistical anomaly” in the number of pre-anaesthetic checks ordered, even though the local hospital generated all these requests. On this basis, the GP was found guilty of incomplete record keeping and misinterpretations of item numbers 723 and 2713. He decided to accept the settlement after trying to sort through the issue over 2 years, although he did not feel at any stage that he had done anything wrong. Despite his previously clear record and full cooperation, he was subsequently fined a substantial five-figure sum and his patients were banned from claiming item 36 from Medicare. The particular case of Dr Tisdall,7 whose disqualification from Medicare was publicised by the PSR, and who fought for 10 years to clear his name, only to die soon after the federal court granted him the right to have his case reviewed by a new committee, is well known in the medical community and in Kyabram where he worked. The Full Federal Court was highly critical of the way the PSR went about making its findings. They described it as making a “speculative assumption” and decisions “simply based upon inferences drawn from statistics”,7 echoing criticisms from medical groups. The PSR is not only the concern of the various medical organisations that have queried its operation. The Australian community are the losers when government bodies fail. This inquiry has given us all the opportunity to improve a system for the benefit of patients, the government and doctors alike. The PSR needs to work hard with all medical and community groups to regain trust and respect.

C Scott Masters FRACGP, FAFMM, DipMusMed · Malcolm I Watt

Opportunities to examine the relevance of health interventions in actual clinical scenarios need to be created Evidence-based medicine underpins high-quality health care.1 The use of evidence in the practice of medicine informs appropriate decision making, reduces variability in clinical practice and helps ensure improvement of patient outcomes. Most evidence relating to new knowledge is derived from randomised clinical trials.2,3 However, evidence from clinical trials necessarily involves small and very carefully selected populations with particular demographics and disease characteristics. Hence, the results of clinical trials are often not directly relevant to clinical reality. In addition, the scientific basis of “standard therapy” against which new interventions are compared has not necessarily been rigorously tested. Uncertainty about how best to use such new evidence versus the range of alternative options available in the “real world” may create variable practices and impair patient outcomes. Paradoxically, evidence from these trials is used by the Medical Services Advisory Committee and the Pharmaceutical Benefits Advisory Committee to make decisions about approval and reimbursement of health interventions. Furthermore, while there are obvious ways by which governments and health insurance funds can constrain the costs of new technology, new services and new drugs before their reimbursement, their capacity to influence the use of existing, funded services in a manner that improves the quality of care is limited. In this article, I outline why comparative effectiveness research — examining the applicability of marketed and/or approved products, services and technologies to clinical reality — is critical to the future of health care in Australia. Such research should be funded by the existing health portfolio, as it would not only help reduce clinical uncertainty but, in an era of increasing cost constraints, could improve the efficiency of health expenditure within the framework of existing funded services. Proposal for a new funding streamIt might be assumed that funding from the current National Health and Medical Research Council (NHMRC) competitive grants scheme is sufficient for gathering comparative effectiveness evidence. However, this scheme tends to be focused on innovation, track record and scientific merit, but comparative effectiveness research may not be seen to be as novel as research that seeks to redefine the boundaries of new knowledge. In the United States, a focus on comparative effectiveness research has emerged as a high priority of the current administration.4 Given the limited pool of funds available for medical research in Australia, I propose a new funding program that is ring-fenced for comparative effectiveness research but administered by the NHMRC, with applications assessed on the basis of scientific merit, innovation, improved health and patient outcomes, and cost offsets. The new funding stream should encourage research that: rigorously tests scientifically based variations in approved or standard health interventions that are publicly funded directly compares the relative roles of approved, publicly funded components of treatment algorithms. A separate funding stream dedicated to clinical research that tests standard health interventions would benefit the community and the government — it would provide a means of optimising the utility of previously funded and approved clinical programs. A simple example of the type of project that such funding might realise is the comparison of variations to approved chemotherapy regimens, most of which are derived from historical practice patterns. For instance, the Short Course Oncology Therapy (SCOT) trial — comparing 6 months of chemotherapy (standard care)5 to 3 months of chemotherapy6 for the adjuvant treatment of operable bowel cancer (to determine whether less chemotherapy is not only less toxic and costly but also equally efficacious) — is currently underway in Australia and Europe.7 In addition, research that compares the components of treatment algorithms — conducted within or across disciplines in relevant populations — would enable optimisation of existing health practices, many of which required no specific approval process to have been introduced into standard treatment algorithms. (Modifications to treatment algorithms are often funded by being absorbed into the Medicare Benefits Schedule [MBS] and/or health insurance funds or by state-based programs.) For example, postoperative radiotherapy as adjuvant treatment for locally advanced gastric cancer is considered one standard of care in Australia and the US.8 Implementation of this modality required no formal approval process and the costs of adding radiotherapy to treatment algorithms were subsumed into the costs of standard care. However, because other studies suggest that perioperative chemotherapy (without radiotherapy) may suffice,9 a comparative effectiveness trial would result in considerable insights into the relative utility of the two approaches, with initial trial-related cost-savings providing substantial offset to the cost of the research. Furthermore, such research can do more than determine the role of radiotherapy in the treatment of operable gastric cancer. For example, in the Trial of Preoperative Therapy for Gastric and Esophagogastric Junction Adenocarcinoma (TOPGEAR), the study design process required agreement on evidence-based surgical standards, standardised pathology examination and reporting, and standard chemotherapy regimens for this disease — none of which relate specifically to the experimental intervention.10 Hence, the research process resulted in clinician engagement in a change process that directly affected quality of care. By reducing variability in clinical practice outside the remit of the clinical trial, the research methodology will help ensure high-quality standards for patients, regardless of whether they are enrolled in the study. Similarly, the process of identifying and prioritising a potential question would help facilitate a change process inside and outside the specific research endeavour. The importance of such downstream effects is fundamental to understanding the potential impact of clinical research on the quality of the health system. Other types of more sophisticated research initiatives that test the interface between imaging, surgery and other techniques or practices, as well as the roles of pharmaceuticals, would undoubtedly emerge if the proposed funding stream were created. In so doing, such funding would enhance the capacity of Australian clinicians to promote the health care quality agenda in a cost-effective manner and across various components of the health system, such as the MBS and the Pharmaceutical Benefits Scheme (PBS). It would ensure that comparative effectiveness research initiatives do not have to compete against projects designed to develop new knowledge. A funding stream for comparative effectiveness research would invite research applications which are primarily designed to promote research into existing, funded health practices. Key criteria in funding decisions could include the likelihood of the research resulting in substantial impacts on the quality of patient care, in large numbers of patients, and the potential of the research to engage the broader health care community in a change process. The funding would not only help establish the relative roles of individual PBS- and MBS-funded interventions, but, from a broader viewpoint, would also show the government how clinical research represents a critical component of health care delivery. It would bring a quality focus to funding agencies concerned with the cost-effective delivery of medical services to the Australian community. Getting the new funding stream startedFunds from the existing health portfolio (MBS, PBS, etc) could be directed to a new NHMRC-administered funding stream of $100 million per annum for comparative effectiveness research. To start the program, the National Institute of Clinical Studies could facilitate development of a list of priority areas in three or more areas of health practice (eg, oncology, gastroenterology and rheumatology) by consultation with professional organisations, government agencies and consumer groups — similar to the list of priorities compiled by the US Institute of Medicine.11 This list could be used to pilot the funding program and could subsequently be extended to cover all areas of health practice. While the priorities within each health area could help inform the peer-review process, the call for applications should not discourage unanticipated ideas. In addition, the program should not be designed to provide a dedicated funding source for health economists — rather, it should encourage collaboration between practising clinicians from various disciplines, including experts in fields such as health economics and health system design. ConclusionA funding stream dedicated to comparative effectiveness research would improve health care quality, foster clinical practice research, and increase efficiency and effectiveness in the health system. It would also highlight the value of clinical research.

John R Zalcberg OAM, MB BS, PhD, FRACP

Three features are essential in designing the flexible funding payments and pay-for-performance elements Performance pay for doctors has been introduced in many countries, including the United Kingdom through the Quality and Outcomes Framework (QOF) and the United States through the patient-centred medical home model.1 The effectiveness of these models remains in question, although there is emerging evidence that these schemes can reduce hospital admissions.2-4 In Australia, the Coordinated Care for Diabetes Pilot (CCDP) begins in 2012.5 The key elements of the pilot (Box) are voluntary patient enrolment, a flexible payment for each diabetes patient to cover allied health services (among other things) and a pay-for-performance element. General practitioners will continue to be able to charge fee-for-service payments and claim diabetes-related payments from the Practice Incentives Program (PIP), but will no longer be able to claim the Chronic Disease Management Medicare Benefits Schedule (MBS) items for GP management plans or team care arrangements.5 Doubts about the effectiveness of financial incentives are raised, not only by poor design of evaluations, but also by poor design of funding models. Careful design, based on theory and empirical evidence, is essential in designing interventions to change professional behaviour.6,7 This helps to ensure that the intervention is likely to be effective, and that unintended and undesirable consequences of incentives are minimised. Our aim in this article is to propose three essential features of the flexible payment-per-patient and the pay-for-performance elements of the new CCDP.8,9 Rewarding improvements in quality of careAn objective of the CCDP is that incentive payments will be paid for: . . . the delivery of patient-centred care in accordance with best practice management guidelines for diabetes, and for achieving improvements in patients’ health against specific indicators.5 Payment should be made for improvements in the quality of care, which requires measuring changes in quality over time. Previous schemes have made payments for the achievement of a level of quality, often based on a relatively high threshold, rather than for an improvement in quality. Using thresholds may not lead to changes in behaviour because: (i) doctors in practices with already high levels of quality of care can claim the highest threshold payment without changing their behaviour; (ii) there are no incentives to go beyond the threshold, and (iii) doctors in practices with low levels of quality of care have little incentive to reach a high threshold, as they perceive the costs to be greater than the financial reward.10 One option is to reward improvements in quality between two time points, and set successive thresholds close together, say at 5% intervals.8 This would encourage those with low baseline levels of quality to improve the quality of their care. Furthermore, economic theory would predict that behaviour is only likely to change if the level of the payment is at least equal to the costs of improving the quality of care. These costs will vary across practices depending on their baseline level of quality and the complexity of the health problems of their patients.3 Allowing payments to vary in line with these cost variations would lead to a potentially more effective intervention. The costs of improving quality of care from 10% to 15% are likely to be lower than those of improving from 90% to 95%. Practices that already attain high standards of care find it difficult and costly to improve further and would not be able to claim an improvement payment. Thus, an element of performance pay should recognise the high performance levels already achieved. The “improvement” payment should be higher than the “achievement” payment, or there would be little incentive for practices to improve their quality of care. Avoiding “cream-skimming” and sharing financial riskA fixed payment per patient gives GPs an incentive to minimise costs, as any surplus from the budget can be kept as personal income or reinvested in patient care, and any deficits are borne by the provider.11 This is good for governments, who want to control costs and ensure costs are predictable, because it shifts the financial risk to GPs. However, if this risk is perceived to be too high, GPs may choose not to participate in the scheme or to enrol only “healthy” patients, so a careful balance needs to be struck between risk-sharing and the strength of incentives. The incentives to minimise costs and “cream-skim” are already ameliorated to some extent in the proposed CCDP. GPs can still claim standard MBS items and PIP payments for their patients with diabetes. Total revenue per patient will vary according to the number of visits made per year, and the length of each visit, which partly reflects complexity. However, this may not cover intensity in terms of the use of other resources in the practice, such as practice nurses or the costs of employing allied health professionals. One option is to “risk-adjust” fixed and performance payments, so that higher payments are made to practices with patients with higher needs or more complex health problems than the average. There is much international literature on this subject, including on the use of risk adjustment in the design of the patient-centred medical home pilots in the US.12 Risk adjustment requires data on the primary care costs of diabetes care for all patients and how this varies according to patients’ characteristics. Unfortunately, there are no routinely available data, and very little information on the use of allied health services by patients with diabetes and the associated costs.13,14 Primary care and hospital data would need to be linked to obtain adequate measures of patients’ severity of illness and diabetes complications.14 It is doubtful whether adequate risk adjustment can be developed and implemented in time for the pilot. However, given continued access to MBS and PIP payments, the additional level of risk for practices under the new scheme may not be high, although this will vary across practices. Avoiding exception reportingA further way that cream-skimming can take place for enrolled patients is exception reporting.15,16 Paying for the proportion of patients who achieve a certain target means that payments are based on a ratio, with the numerator equal to the number of patients reaching the target and the denominator equal to the number of patients in the population. Exception reporting occurs when practices exclude patients from the denominator, thus increasing measured performance and earning income, while not improving quality. For example, in the first year of the UK Quality and Outcomes Framework, a median of 5.4% (range, 0–40%) of practices used exception reporting for patients with diabetes. This translated into median gains of between £1700 and £15 000 per practice.15 One way to avoid exception reporting is to make payments based on the numerator only — that is, on the number of patients whose quality of care improves from one period to the next. This would involve a payment for each patient achieving a desired change in performance. Payments can only be increased from one time period to the next if the number of patients achieving a target, or whose quality of care improves, increases. ConclusionThe design of the new payment system in the CCDP should attempt to maximise the impact of the incentives on quality of care while also ensuring an “appropriate” sharing of financial risk with providers, in addition to minimising any unintended consequences, such as exception reporting and cream-skimming. This will partly depend on the validity and reliability of quality indicators, but experience from the Australian Primary Care Collaboratives Program suggests that such data can be extracted from practices. The balance of additional revenue between the flexible payments and performance-pay elements is also crucial, and can influence behaviour as well as costs. Careful design of incentive schemes is essential for their success. Current and new mix of payments for patients with diabetes under the Coordinated Care for Diabetes Pilot (CCDP) Payments Current mix New mix of payments in the CCDP*† 1. Fees for professional attendances For each visit, general practitioners can charge patients what the market will bear, and patients claim (often via their GP) a fixed rebate determined by the MBS. No change‡ 2. Practice Incentives Program Practices can claim payments for patients with diabetes within the PIP (the diabetes sign-on payment, the diabetes service incentive payment for completing a three-visit cycle of care, and the outcomes payment for each diabetes patient if the practice has completed cycles of care for at least 20% of their patients with diabetes). Practices in rural areas (RRMA 3–7) receive a loading on all PIP payments (including diabetes payments) of between 15% and 50%. No change 3. Fees for GP management plans and team care arrangements GPs can claim under MBS items 721 (development of a GPMP), 723 (development of TCA) or 732 (review of a GPMP or TCA). These are fees for each visit (so standard professional attendance fees cannot be claimed), with one GPMP or TCA claim allowed in 12 months (with some exceptions) and one review claim once every 3 months. Patients being managed under the chronic disease management items may be eligible for: allied health services (MBS items 10950–10970); and/or allied health group services (MBS items 81100–81125); and/or dental services (MBS items 85011–87777). There are restrictions on claiming both SIPs and GPMP/TCA/review payments. Practices can no longer claim these fees 4. Flexible funding None A single payment per enrolled patient per year 5. Pay for performance See PIP diabetes outcome payment for completion of cycles of care above. Payments related to improvements in quality of care — to be designed GPMP = GP management plan. MBS = Medicare Benefits Schedule. PIP = Practice Incentives Program. RRMA = Rural, Remote and Metropolitan Areas classification. SIPs = service incentive payments. TCA = team care arrangements. * There are other indirect funding sources for the care of patients with diabetes, including funding for practice nurses, which changed in late 2011 from practice nurse MBS items and payments under the PIP scheme, to fixed subsidies for practice nurse and allied health salaries under the Practice Nurse Incentive Program (http://www.medicareaustralia.gov.au/provider/incentives/pnip.jsp). † The levels of payments are to be determined as part of the implementation of the CCDP. ‡ To the extent that the scheme leads to more visits by patients with diabetes, this will also increase costs to the MBS.

Anthony Scott BA(Hons), MSc, PhD · Mark F Harris MB BS, FRACGP, MD

Australia’s Medicare Locals are in a formative period, and any comparison so far has focused on the United Kingdom The Australian and Canadian health systems share many similarities; one author has described them as “children of a common mother”.1 The fundamentals of the provision of primary care in both countries are the same: the overwhelming majority of “general practitioners” in Australia and “family physicians” in Canada work in independent practices, billing “Medicare” on a fee-for-service basis. The structure of family practice is similar, with a mix of solo and multiphysician practices. In Alberta, patients are not required to register with a single practice, but many family practices are not accepting new patients, and so registration with a practice is universally seen as desirable. There is no financial penalty (on the patient or the practice) for patients seeing a physician outside the practice in which they are registered. There are some differences; most notably that health care in Canada is essentially a provincial responsibility operating within overall parameters set by the Canada Health Act, and that “extra-billing” (billing above the schedule fee) is prohibited. The health systems in both countries face similar challenges in meeting the needs of primary health care: improving access, especially in rural and remote areas; better managing chronic disease; developing more effective links between primary care and hospital practice; and working out how to foster multidisciplinary teams. Alberta’s answer to these challenges has been to develop Primary Care Networks (PCNs), which may provide useful lessons for the establishment of Medicare Locals in Australia. Alberta is one of Canada’s western prairie provinces, with a population of 3.7 million, covering a geographic area about three-quarters the size of New South Wales. In 2009, Alberta had 113 family physicians per 100 000 population (4187 family physicians).2 The first PCN was established as part of the funding agreement between the province and the Alberta Medical Association in 2005. There are currently 39 PCNs in Alberta, and about 75% of family physicians work in practices that are members of PCNs.3 How PCNs functionPCNs are organisations of practices — the PCN itself does not enrol patients and does not run the practices. PCNs are eligible for a capitation payment of $50 per patient (for the purposes of this comparison, the Australian dollar can be assumed to be on a par with the Canadian dollar). PCNs are required to submit a “business plan” to Alberta Health Services (the provincial provider organisation responsible for the flow of funds to the PCNs) about how the capitation funding would be spent. Considerable flexibility is permitted in the structure and content of business plans, which allows for local variation in priority setting. PCNs range in size in terms of both the number of physicians linked to them and the number of patients served. PCNs in rural areas are smaller on both dimensions. PCN governance reflects both physician autonomy and the need for accountability to the funders (Alberta Health Services, and the relevant government department, Alberta Health and Wellness), reflected in two decision-making fora: a physicians’ board (known colloquially as the “Little Board”) and a PCN board (“Big Board”) with representatives of the funding organisations. The Big Board thus provides a direct link between the PCN and senior local Alberta Health Services leaders who are responsible for wider health issues. The PCN budget is derived from the capitation payments used to cover administrative costs of the initiative, which include employing an executive director responsible to the Little Board, employing allied health or mental health staff (often based in individual practices), and providing other support functions (eg, supplying comparative data). Evaluation of PCNsStakeholders see collaboration as the principal benefit of PCNs, and the provision of improved access to allied health care as one of their greatest strengths. “Collaboration” is used broadly here, to refer not simply to relationships between physicians and allied health professionals but also to relationships between physicians and the rest of the health system. In recent interviews with family physicians involved in PCNs in Alberta, conducted by one of us (A S, as part of a medical student placement), one physician stated that, “The PCN initiative has saved primary health care in Alberta”. Another, who holds positions on both the Little and Big Boards of a larger PCN, stated: Of the most important things which the PCN has achieved for our province, the first would be the re-involvement of family physicians with the health system, since, before this, they had been somewhat isolated; and the second [would be] better use of the full extent of capabilities and intelligences on offer from allied health professionals. There are disadvantages of the current PCN arrangements, including a lack of clarity with regard to general PCN direction, which stems from the autonomy in setting priorities granted to PCNs to allow maximum flexibility in responding to local needs. What can PCNs offer Medicare Locals?Strengthening primary care has been a catchcry of health reform efforts around the world for decades. The most recent Australian example is the report of the National Health and Hospitals Reform Commission.3 However, primary care is complex and reform is hard to achieve. One strategy has been to attempt to strengthen primary care by developing a stronger organisational base for it — initially, in Australia, through Divisions of General Practice,4,5 and more recently, through Medicare Locals.6 Divisions have been successful on a number of dimensions,7 although the administrative arrangements at both national8 and local levels9 have not been perfect. Arrangements for Medicare Locals are still evolving, and their evolution could benefit from taking note of similar strategies in other countries. Alberta’s PCNs have something to offer here as they have proven themselves to be a vital part of continued access to primary health care in the province. Although the Canadian and Australian health care systems are similar, they are not identical. Some aspects that may be portable are: Capitation funding — means that PCNs know how much they can expect and can plan accordingly. Depending on their size, PCNs receive up to $15 million per annum to be distributed in line with business plans. A dual board system — provides a compromise between physician autonomy in management of the PCN while allowing delegation of some decisions to the physician group. It has some parallels to the German approach of management and supervisory boards.10 An evolutionary approach — incorporating a slow phase-in means the system is not being imposed on any physician or practice and allows skeptics to evaluate the benefits of local cooperation. The first PCN was established more than 5 years ago, but some practices have not yet linked up to a PCN, despite the financial incentives. Alberta appears to have invented a wheel for primary care that is supported by family physicians. Australia could learn from this example without needing to totally reinvent it.

Andrew Suchowersky BMedSci(Hons) · Oksana Suchowersky MD, FRCPC, FCCMG · Stephen J Duckett PhD, DSc, FASSA

Major reform plus targeted strategies have the potential to provide relief Underpinning recent global health initiatives, including the Millennium Development Goals and the United Nations’ High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, has been recognition of the links between illness, disability, poverty and economic development. In Australia, the economic effects of illness, particularly long-term illness and disability, are often overlooked or examined exclusively in terms of the consequences for government budgets and the economy. While such analyses may be effective in alerting policymakers to the scale of particular epidemics, they provide little indication of the direct impact of illness on the wellbeing of those in the community. To do this, the unit of analysis needs to be shifted from the macro economy to individuals and households. The existence of universal publicly funded health care and social security arrangements has possibly encouraged complacency among researchers and policymakers about tackling this issue. However, there is emerging evidence in Australia that chronic illness and disability are associated with serious levels of economic hardship and that such hardship affects health behaviour1-3 — thereby completing a cycle in which poor health leads to poverty, which then leads to poor health. The economic consequences in question include not only the out-of-pocket costs of medical treatment, but also the costs of self-management (eg, home modifications, transport and paid care) and loss of income for patients and carers.1,3,4 As a result, those of low socioeconomic status are at greater risk of experiencing illness and disability and are more vulnerable to the consequences. Out-of-pocket costsThe most direct manner in which the economic impact of illness is felt is through the out-of-pocket costs of care. In Australia, despite a free public hospital system and universal social health insurance coverage through Medicare, levels of out-of-pocket payments are high by international, high-income country standards. In a recent Commonwealth Fund survey of 11 high-income countries, the incidence of out-of-pocket spending exceeding US$1000 in the previous year among individual respondents was 21% in Australia — behind only the United States (35%) and Switzerland (25%), and well above countries such as the United Kingdom (1%), France (4%) and New Zealand (7%).5 In 2009, out-of-pocket spending as a proportion of total health expenditure was 18.2% in Australia — above the Organisation for Economic Cooperation and Development (OECD) median of 15.8% (Box 1).6 This proportion has remained steady in Australia, not varying much from the 1999 value of 19.9%, and seems unlikely to change given one of the recommendations of the National Health and Hospitals Reform Commission: “We want to see the overall balance of spending through taxation, private health insurance, and out-of-pocket contribution maintained over the next decade.”7 It is hard to see any compelling fiscal justification for such a policy when a comparison across OECD countries indicates that public spending on health in Australia in 2009 (5.8% of gross domestic product) was well below the OECD median (6.9%).6 What are the implications of these costs?The picture emerging from recent studies in Australia is that major burdens are being imposed on particular patient populations by high out-of-pocket costs.1-4 For example, in a study of patients with chronic obstructive pulmonary disease (COPD), 46% of patients experienced an incidence of catastrophic health care spending — defined as out-of-pocket costs exceeding 10% of income for the period studied.1 The main out-of-pocket costs incurred by these patients are shown in Box 2. In general, evidence suggests that the high burden of out-of-pocket costs tends to be skewed toward those with comorbidity1 and those with more severe illness.8,9 However, the hardship related to such burden tends to be most pronounced in people who have retired1 and those of low socioeconomic status,1 and there is little evidence of concession or insurance status providing significant protection.1,10 In addition, substantial costs incurred by patients are often not for health care but for home modifications, social support and transport.1,3,4,10 Significantly, increasing levels of out-of-pocket costs associated with copayments for PBS-listed medications have been found to be associated with reduced rates of prescriptions being filled.2 Such findings are supported by evidence from a qualitative study of patients with chronic illness in western Sydney and the Australian Capital Territory; lack of affordability of medical treatment, and thus impaired ability to self-manage, was a major aspect of economic hardship for these patients.3 Putting these findings into context, over the past 10 years the out-of-pocket burden associated with both MBS-listed medical services and PBS-listed medications has increased substantially (by 4.2% and 6.7% per year respectively).6 The concern is that these rising levels of copayment will adversely affect compliance, particularly in patients who require long-term treatment. Indirect costsIllness and disability also affect household economic circumstances through their effect on employment. In 2006, 33% of 18–64-year-olds who reported specific limitations or restrictions lived in households in the lowest income quintile, compared with 10% of those without such impairment.11 This pattern is further pronounced in individuals with intellectual disability and severe or profound disability, with 40% and 36% of people in these groups, respectively, living in the lowest income quintile households.11 This impact extends to informal carers, who often leave paid employment to care for a sick family member. While there are income support programs in place to assist those with long-term illness and their carers, often these barely cover living and medical expenses.3 Nevertheless, the prospect of losing income support payments and concessional status as a result of resuming employment can create a welfare trap for patients and carers, particularly those in low-income occupational groups. Financial stress and illness-related povertyIn Australia in 2009, 28 665 individuals became bankrupt, of whom 11% cited ill health or absence of health insurance as the primary reason.12 While illness-induced bankruptcy is not as large a problem in Australia as it is elsewhere (such as the US, where it caused 62% of bankruptcies in 200713), significant numbers of Australians are catastrophically affected by illness. In addition, disability has been found to be associated with more acute measures of economic hardship, such as financial stress based on an individual’s ability to raise a sum of money for something important. The Australian Institute of Health and Welfare (AIHW) has found that individuals with specific limitations or restrictions, when compared with those without impairment, report over double the rate of being unable to raise $2000 (26% v 11%).11 Another criterion for assessing financial stress is the inability to make necessary household payments. According to the AIHW, 34% of 18–64-year-olds with specific limitations or restrictions reported at least one such incident in the previous 12 months, compared with 18% of those without impairment.11 One study which adopted this broader perspective of examining the economic impact of illness and disability on households found that, in patients with COPD in western Sydney, 78% reported at least one instance of being unable to make necessary payments in the previous 12 months or, to do so, needed help, sold assets, moved house or borrowed money.1 Similarly, in individuals participating in the Household, Income and Labour Dynamics in Australia (HILDA) Survey, a population-based longitudinal survey, such incidences of financial stress were found to be strongly associated with disability, poor physical function and poor mental health.14 What can be done?The studies conducted in Australia indicate that health-related economic hardship tends to disproportionately affect specific patient populations, largely due to costs that are conventionally treated as being unrelated to the health sector. In the absence of comprehensive evidence, it is only possible to gather findings from a patchwork of unrelated studies. Priority should therefore be given to developing a consistent approach that records the specific costs to individuals and their households associated with illness and identifies the impact of these costs on health behaviour and wellbeing. The available evidence indicates that the out-of-pocket costs of treatment and self-management and loss of income from chronic illness and disability are associated with economic hardship, catastrophic health care spending and non-compliance with medical treatment. Major reform, such as the recently proposed National Disability Insurance Scheme (NDIS), has the potential to address hardship associated with illness and injury. However, meaningful improvement is also possible through small-scale targeted strategies. As household economic burden is skewed toward specific patient groups, effective remedies could include focused interventions such as income support and subsidies. These measures would identify and catch those individuals and households that currently fall through the cracks. They would also be unlikely to involve changes that distort current health care priorities or restructure the responsibilities of different government sectors. Furthermore, they could be implemented quickly. Ultimately, both broad-brush policies such as the NDIS and targeted support measures are needed to provide direct relief to individuals and households most at risk of illness- and disability-related economic hardship. 1 Out-of-pocket costs as a share of total health expenditure in OECD countries, 2009* OECD = Organisation for Economic Cooperation and Development. * Reproduced with permission from the Australian Institute of Health and Welfare.6 2 Main out-of-pocket costs associated with managing chronic obstructive pulmonary disease1 Home oxygen and medications Transport Medical consultations and tests Home care Medical equipment

Stephen Jan BEc, MEc, PhD · Beverley M Essue MPH · Stephen R Leeder BSc(Med), MD, PhD

Supply must meet demand to maintain our high standards of cancer care Recent years have witnessed significant progress in cancer treatment, with improved outcomes,1 treatment options, emergence of survivorship care, and acceptance of multidisciplinary care as the optimal care delivery method.2 All Australian states have cancer plans, and considerable funding has been committed to cancer control by state and federal governments. While cancer outcomes in Australia are excellent by world standards, cancer care providers and consumers are concerned about the ability of the oncology workforce to meet the growing demand, and the effect that shortages may have on the quality of care. The number of new cases of cancer continues to increase by about 3% per year because of increased population, improved longevity and increased detection rates. Over a decade, the increase amounts to nearly 40%.1 The expansion of cancer services has barely kept pace with the increased number of cases, and the number of training positions, while highly in demand, is not sufficient to address the need.3 This concern is illustrated by a recent major federal government investment into rural cancer centres of $560 million.4 The funding is subject to a partnership agreement with the states to ensure an adequate workforce (as well as other recurring costs) to deliver care in rural centres. With 20 facilities to be created or expanded with federal funding, and others developed with state support (10 additional facilities in South Australia alone), there can be only two potential strategies for workforce supply. One is to create new positions (unlikely to be successful, given the national and international shortages in the cancer workforce and no specific commitment of additional funding for that purpose); the other is to redistribute the existing workforce and optimise work practices to manage additional demands. It seems prudent to consider these possibilities in some depth, and we have done so using information from the recent workforce survey of the Medical Oncology Group of Australia (MOGA).5 Medical oncology is a key element of multidisciplinary cancer care, and is thus fundamental to services in the proposed rural expansion. It is estimated that about half of cancers require treatment with at least one course of systemic therapy.6 Medical oncologists (MOs) frequently supervise chemotherapy, targeted therapies, treatment with biological agents and hormonal therapy. They may be responsible for care coordination and provide supportive, palliative and follow-up care. The MOGA survey demonstrates that currently in Australia there is a significant shortage and uneven distribution of MOs that is unlikely to be addressed by the increase in training positions. Of even more concern is that the estimated chemotherapy utilisation rate (the proportion of new patients with cancer who receive chemotherapy at least once during their illness) appears to be less than half the recommended rate.5 There is no indication that MOs turn patients away (although the subject was not specifically covered in the survey), and it is likely that the low chemotherapy utilisation rate may reflect limited access to MOs or limited awareness about the value of medical oncological treatment among referring doctors. Increasing engagement of MOs with other doctors and development of rural centres may help solve these problems. But the concern remains that with the existing medical oncology workforce, we simply do not have the capacity to increase the chemotherapy utilisation rate. The federal government investment in infrastructure for rural cancer centres is one example of the challenges for the cancer workforce in general. The current workforce of 234 full-time equivalent (FTE) MOs will need to absorb the work demands of the additional 20 rural facilities. Even allowing an average of 0.5 FTE MOs per site, this would require an increase of 10 FTE MOs, which seems hard to achieve, given that 29 FTE MO positions are currently unfilled. Some patients who would be seen in the rural centres are currently seen in metropolitan facilities, so there will be some shift in workload, but there will also be a need to allow time to travel, especially in states where the population density is such that there is just not enough work for a resident MO. There will also be a cost associated with taking an MO out of the existing facility to provide care elsewhere. We do not claim that these figures are precise, but they illustrate the calculations that may be required and are yet to be presented. We hope that raising these issues may serve as a call to action, because without thoughtful strategies to increase the oncology workforce, the investment of $560 million may not reach its full potential. So what can be done? We argue that quite a lot can be achieved. The medical oncology profession is committed to promoting best practice and monitoring workload and current and future demand to deliver care with the highest quality and safety, as close as practicable to patients’ homes. MOs are open to innovation and welcome nurse practitioners, physician assistants and other innovative health care delivery strategies, including shared-care models, role redesigns and “e-health” solutions that can improve efficiency and access to care. Every effort should be made to reduce inefficient and unnecessary care; for example, use of chemotherapy when palliative care may be more appropriate, and MO management of patients who may be more appropriately followed up in general practices. The solutions need to be feasible, and consistent across the public and private (which currently has less access to innovative models of care delivery) sectors. The federal government has established two agencies with significant roles to play: Cancer Australia and Health Workforce Australia. These agencies and the profession must jointly address the challenges ahead in order to solve problems across jurisdictions — across state and federal boundaries, rural and metropolitan areas, the public and private sectors, government and training colleges and across professions. Just as we recognise that clinical care can best be delivered in a multidisciplinary setting, we need to start planning cancer care in the multidisciplinary setting. We know that work shortages described in medical oncology are similar to those in other disciplines, and addressing shortages in one area in isolation will not solve the problem; solutions must encompass the entire spectrum of cancer care professionals. Australia is unique internationally in having a strong professional multidisciplinary cancer organisation (the Clinical Oncological Society of Australia) that can engage cancer providers across disciplines. Now we need the jurisdictions to work with Cancer Australia and Health Workforce Australia in conjunction with the professional groups and consumers. We have seen the benefits of this approach already, in radiation oncology. The Radiation Oncology Reform Implementation Committee, under the auspices of the Australian Health Ministers’ Advisory Council, has driven significant improvements in delivery and staffing in Australia, and was another driving force for the regional cancer centre initiative. We need to apply similar processes to delivery of systemic anticancer therapies. We need to better define the problem. The MOGA survey is a good start, but points out one serious limitation: without national investment into robust data collection systems, we will not be able to plan effectively or monitor outcomes of interventions. The MOGA survey calls for a national cancer workforce plan that can provide projections and recommendations for the future. It takes 13 years to train an MO from the time of entry into medical school. To plan for the 40% growth in cancer incidence over the next 10 years, we need to invest in new training positions today, focusing not only on numbers of places but also on creating systems allowing people to work more efficiently and flexibly, so we not only attract them to the profession but retain them at peak performance. We need to agree as a society what standards of care we aspire to and what standards we can realistically deliver. How many patients can we reasonably expect an MO to see without risking burnout or dangerous errors occurring? We need to engage consumers in some difficult conversations on how we can provide the best care, not in the ideal setting, but in the reality of our limited (human) resources. Australia has one of the highest standards of cancer care in the world, but we can do even better with appropriate staffing, quality and distribution of our cancer care workforce. It is time to come together to start addressing the looming shortages before it is too late.

Bogda Koczwara MB BS, FRACP, MBioethics · Michael B Barton OAM, MB BS, FRANZCR · Euan T Walpole MB BS, FRACP · Peter Grimison MB BS(Hons), PhD, FRACP · Prunella L Blinman BMed, FRACP · Sally Crossing AM, BEc · Kay Francis BA(Hons), MA(Hons), MBA

To the Editor: We read with interest the article by Pinto and colleagues regarding colonisation of reusable tourniquets by multiresistant organisms (MROs).1 We highlight that surgical adhesive tape also has the potential to act as a significant fomite in health care settings. We collected partially used surgical tape rolls from several clinical areas of three hospitals in the Hunter New England Area Health Service. Using hands disinfected with alcohol gel, tape rolls from different locations in each area were placed into 21 clean collection bags (up to three tapes per bag). Tapes from each batch were placed in 21 sterile containers with 15 mL of brain–heart infusion broth and incubated overnight at 35°C in carbon dioxide. The broths were subcultured onto Columbia horse-blood agar (Oxoid Australia, Adelaide, SA), MacConkey agar (Oxoid) and differential selective media to detect vancomycin-resistant enterococci (VRE) (chromID VRE; bioMérieux, Marcy L’Étoile, France), methicillin-resistant Staphylococcus aureus (MRSA) (Brilliance MRSA; Oxoid) and multiresistant gram-negative bacteria (chromID ESBL; bioMérieux). A multiplex tandem polymerase chain reaction assay (MRSA4; AusDiagnostics, Sydney, NSW) to detect MRSA and methicillin-susceptible S. aureus (MSSA) was also performed on all broth cultures. Routine species level identification was performed (VITEK MS; bioMérieux). Susceptibility was determined in accordance with Clinical and Laboratory Standards Institute criteria.2 In 11 of the 21 tape batches, MRSA and/or VRE were identified. Of these, four were positive for MRSA and 10 for VRE, with three positive for both. MSSA was identified in two, both in association with VRE. All batches showed evidence of contamination with other bacteria such as Bacillus cereus, coagulase-negative staphylococci, non-multiresistant Enterobacteriaceae, Pseudomonas spp, Acinetobacter spp and other enterococci. Our results indicate that surgical adhesive tapes are frequently contaminated with MROs. Interpretation of these results is limited by the small number of tapes and clinical areas sampled, and the difficulty of proving a relationship to clinical infection. However, items such as intravenous cannulae, surgical drains and wound dressings are frequently fixed using surgical adhesive tape. This may lead to colonisation and subsequent infection. Furthermore, tape rolls are often left lying on contaminated surfaces, are handled by multiple individuals and cannot be disinfected. Surgical adhesive tape is a potential reservoir of pathogenic bacteria3 and fungi4 and was implicated in a prolonged S. aureus outbreak in a neonatal unit.5 The role of surgical tape as a potential fomite was reported in 19746 but has not been widely acknowledged since. Removing the outer layer of the tape roll is unlikely to reduce contamination, given visible contamination of the side of many rolls (Figure).3 Short rolls of surgical adhesive tape should be supplied in sealed packets and used for individual patients, only after hand disinfection, and discarded after use.

Patrick N A Harris · Chris Ashhurst-Smith · Sandy J Berenger · Alison Shoobert · John K Ferguson

To the Editor: Antimicrobial resistance has been identified as a major concern in Australia, particularly as few new antimicrobial agents are being developed.1 Studies suggest that up to half of antimicrobial agents prescribed in hospitals are inappropriate.2-4 Antimicrobial stewardship interventions, including dissemination of clinical guidelines and restrictions on antimicrobial formularies, may not be fully able to account for the complex indications for antimicrobial use in hospitalised patients. We instituted a rapid clinical audit and feedback system of patients on one of 14 restricted antimicrobial agents as a component of antimicrobial stewardship activities in 2011 at the Alfred Hospital in Melbourne. Multidisciplinary antimicrobial stewardship ward rounds involving a senior clinical pharmacist, an infectious diseases (ID) registrar and an ID physician were performed on weekdays. Patients in units (respiratory, haematology/bone marrow transplantation, burns and intensive care) who had existing liaison ID services were excluded from our analysis. Patients included in the analysis were prescribed a restricted antimicrobial, either for an indication outside hospital policies, or where approval had not been obtained through a web-based antimicrobial approval system. Between January and April 2011, 473 patients were identified as requiring review by the antimicrobial stewardship team. In total, 236 recommendations (Box) were made for 158 patients across all 18 units (73% surgical, 27% medical). For other patients, antimicrobial use was deemed clinically justified or the antimicrobial agent had been ceased at the time of review. Recommended changes to therapy involved ceftriaxone (n = 70), piperacillin/tazobactam (n = 23), ciprofloxacin (n = 22) and vancomycin (n = 18). A formal referral to the ID consultation service was made for 11 of the 236 patients (5%). Recommendations were followed in 78% (184/236) of cases; acceptance of recommendations was higher when review involved the ID physician (146/176, 83%) than when it did not (38/60, 63%; P = 0.002). Rapid clinical review by a multidisciplinary antimicrobial stewardship team was able to assess large numbers of patients requiring restricted antimicrobial agents. Postprescribing evaluation has been reported mainly in North American studies, but has not been reported in Australian hospitals.5 In most patients, agreement was reached with the treating clinicians to cease or reduce the use of antimicrobial agents, suggesting that their ongoing use was not clinically justified. In addition, regular ward rounds by the team supported compliance with the antimicrobial approval system, provided education to junior medical staff and identified antimicrobial use protocols that had no basis in evidence. Proportion of the antimicrobial stewardship team’s recommendations accepted Recommendation Accepted Stop antimicrobial agent 72% (56/78) Change drug dose 75% (33/44) De-escalate antimicrobial cover 83% (25/30) Change to oral antimicrobial agents 90% (26/29) Change drug to alternative 88% (21/24) Formal infectious diseases consult 64% (7/11) Initiate antimicrobial 73% (8/11) Additional management 100% (4/4) Additional diagnostic procedures 67% (2/3) Therapeutic drug monitoring 100% (2/2) Total 78% (184/236)

Kelly A Cairns · Adam W J Jenney · Sushena Krishnaswamy · Michael J Dooley · Orla Morrissey · Sharon R Lewin · Allen C Cheng

To the Editor: The median age of Australian patients at first diagnosis of cancer is 67.8 years.1 In advanced, incurable cancer, goals of treatment include symptom control for all patients and prolongation of survival by weeks to months in a subgroup. In older people, treatment decisions can be complicated by comorbidities, polypharmacy, frailty and cognitive impairment. Few studies have investigated older patients’ information needs and preferences for involvement in decisions about their care.2,3 We performed an exploratory study to investigate whether the health status of older cancer patients predicted their information needs, decision preferences and their oncologists’ treatment recommendations. Concordance between patients’ stated preferences and the perceptions of their oncologists was also measured. Fifty outpatients with advanced lung (n = 30) or bowel (n = 20) cancer, with a mean age of 66.9 years (range, 51–91 years) participated. Fourteen patients (28%) were older than 70 years and 80% were diagnosed with advanced cancer within the previous 4 months. Patients’ health status was measured using the Vulnerable Elders Survey (VES) 13, a validated questionnaire used to identify older persons at risk of health decline (indicated by scores of ≥ 3).4 Role preferences were elicited using the Control Preferences Scale.5 Thirteen patients (26%) had VES 13 scores of ≥ 3. Of these, five (38%) were over 70 years. Twenty-six of 49 patients (53%) wanted a passive role in decision making, and 29 of 50 patients (58%) wanted prognostic information. Age and VES 13 scores did not predict patients’ role preferences or desire for prognostic information. Oncologists were less likely to recommend chemotherapy for patients over 70 years (25% v 75%, P = 0.04) or for those who had VES 13 scores of 3 or above (20% v 80%, P = 0.02). Concordance between patients’ participation preferences and oncologist perceptions was 54%. Until there is more evidence from larger studies of patient preferences, oncologists should ask patients their preferences about decision making and prognostic information. Patients with advanced cancer, by characteristic and preference Characteristic Prefer non-passive decision control* Prefer prognostic information Total patients (n = 50) 23 29 Age 50–60 years 6 7 Age 61–70 years 11 14 Age 71–80 years 5 5 Age > 80 years 1 3 Male 10 18 Female 13 11 Born in Australia 15 14 Born outside Australia 8 15 Bowel cancer 13 19 Lung cancer 10 10 0 comorbidities† 3 5 1 comorbidity† 3 5 2 comorbidities† 4 7 ≥ 3 comorbidities† 12 12 0 concomitant medications‡ 1 4 1 concomitant medication‡ 2 3 2 concomitant medications‡ 7 5 ≥ 3 concomitant medications‡ 13 15 Lives alone 8 9 Lives with someone 15 20 Lives in aged care facility 0 0 ECOG PS = 0–1 20 24 ECOG PS = 2–3 2 4 Married 9 13 Not married 14 16 Primary education§ 3 5 Secondary education§ 14 14 Tertiary education§ 5 10 VES 13 score = 0–2¶ 17 19 VES 13 score = > 3¶ 6 10 ECOG PS = Eastern Cooperative Oncology Group performance status; higher score = poorer status. VES = Vulnerable Elders Survey. * Total in passive and non-passive categories was 49 (one patient gave no preference). † Missing data for one patient. ‡ Missing data for three patients. § Missing data for two patients. ¶ VES 13 scores range from 0–10; scores > 3 indicate vulnerability to health decline.

Lakshmi P Venkateswaran · Phyllis N Butow · Jesse Jansen · Nicholas R C Wilcken · Mark K Wong · Rina Hui · George Szonyi · Val J Gebski · Vasi Naganathan · Lisa G Horvath · Martin H N Tattersall

To the Editor: Multidisciplinary meetings (MDMs) are recognised as crucial to best practice in oncology, and governments have designated MDMs as key priorities in cancer care.1,2 Improvement in overall survival has been promoted as a potential benefit of multidisciplinary care, with little supporting evidence. However, consensus MDM decisions are worthless unless action is subsequently implemented. This retrospective audit aimed to assess whether MDM recommendations were implemented, as an indirect measure of the MDM process on patient outcomes. MDM records for patients discussed at the Austin Health (Melbourne) Uro-Oncology, Upper GI (gastrointestinal) and Colorectal Cancer MDMs between February and April 2010 were reviewed, and consensus recommendations were compared with treatment plans documented in the medical record. Reasons for change in management were classified as (1) new clinical information unavailable to MDM; (2) patient’s choice; (3) comorbidities or patient performance status; or (4) not otherwise specified. The Box summarises the results. Overall concordance was 76% (152/201 records). In 41 records (20%) in which an MDM discussion was documented, data were not available due to missing or incomplete MDM documentation in the medical record. Excluding records where data were unavailable, concordance was 95% (152/160 records), with discordance due to new clinical information (5), comorbidities or performance status (2) and patient choice (1). These results highlight a few issues. Documentation of MDM discussion and consensus decision is required for the MDM recommendations to be delivered to patients and communicated to other clinicians. This documentation may have been missed due to differences in recording systems (paper versus electronic; designated person recording) or MDM structure (pre-specified agenda versus ad-hoc discussion), which need to be addressed. The high concordance rate (where documentation was available) suggests that MDM management recommendations are being delivered and acted upon, and so effectively promote high-quality, evidence-based care. This assumes that the MDM always uses evidence-based medicine and includes all relevant members of the treating team. This aspect was not analysed as part of this audit. However, in support of this assumption, we found that neoadjuvant chemotherapy for stage T3 or greater muscle-invasive bladder cancer was not given before institution of MDMs in 2007 (0/19 potential patients), but is now regularly discussed at the Uro-Oncology MDM and is administered where appropriate (7/20 patients between 2007 and 2010). This suggests a positive effect of this MDM on access to a therapy known to improve survival. Our findings suggest that MDM recommendations are usually acted upon and improve patients’ access to appropriate treatment.3 Results of an audit of records of Uro-Oncology, Upper GI (gastrointestinal) and Colorectal Cancer multidisciplinary meetings, Austin Health, February – April 2010 Total no. of records Data not available, no. (%) Overall concordance, no. (%) Concordance when data available, no. (%) Discordance, no. (%) Uro-Oncology 118 32 (27%) 85 (72%) 85 (99%) 1 (1%) Upper GI 40 3 (8%) 34 (85%) 34 (92%) 3 (8%) Colorectal 43 6 (14%) 33 (77%) 33 (89%) 4 (9%) Total 201 41 (20%) 152 (76%) 152 (95%) 8 (4%)

George H Au-Yeung · Ahmad Aly · Andrew Bui · Carmel M Vermeltfoort · Ian D Davis

To the Editor: Return to driving following a stroke is a complex issue. Austroads provides general guidelines1 and the National Stroke Foundation recommends a process including off-road and on-road driving tests.2 On-road assessments conducted by occupational therapists are considered the gold standard for decision making on return to driving following a stroke. Limited access is available to off-road and on-road tests across Australia, with few occupational therapists qualified to assess driving ability. Additionally, a range of off-road assessments are used for patients who have had a stroke. General practitioners, who are instrumental in managing return to driving, often base their decisions on limited information regarding functional status, particularly in terms of vision, cognition and perception. Rehabilitation physicians generally have access to more detailed information from allied health staff on which to base their decisions on driving ability. I investigated whether rehabilitation physicians’ recommendations on driving following a stroke were associated with patients’ performance on two objective tools, which could be used in general practice to assist with decision making. Participants were recruited at two rehabilitation services in Adelaide, South Australia, using the following inclusion criteria: had been diagnosed with stroke; had driven before the stroke; were aged over 18 years; and had provided written informed consent. I performed two assessments. The first was the Useful Field of View (UFOV) assessment;3 this is a computer-administered assessment that analyses processing speed, divided attention and selective attention, and takes 20 minutes to complete. The second was the Stroke Drivers Screening Assessment (SDSA);4 this consists of three tests conducted at a table — dot cancellation, compass recognition and road sign recognition — and takes 45–60 minutes to complete. Both assessments have been validated in patients who have had a stroke by comparison to on-road assessment.5 Treating rehabilitation physicians, blinded to assessment results, were contacted to obtain their recommendations on driving ability based on their clinical assessment and feedback from allied health staff at a case conference. A total of 123 participants (98 men [80%]) were recruited, and diagnoses included 53 right hemisphere strokes (43%), 63 left hemisphere strokes (51%) and 7 other strokes (6%). The participants’ mean age was 67.3 years (SD, 13.5 years), median period since injury was 42 days (range, 7–2190 days) and mean amount of driving experience was 48 years (SD, 14.9 years). Results of the SDSA (n = 120) and UFOV assessment (n = 123) were significantly associated with rehabilitation physicians’ recommendations on driving (Box). This suggests that referring patients who have had a stroke for one of these assessments would provide GPs with objective information to guide decision making on driving. With the introduction of Medicare Locals, resources that allow GPs to refer patients for standardised off-road driving tests should be considered. Rehabilitation physicians’ recommendations on driving for patients with a stroke diagnosis and results of two off-road assessments Rehabilitation physicians’ recommendations (number of patients) Not medically fit to return to driving On-road assessment required Return to driving — no on-road assessment required P SDSA results Pass (n = 61) 5 36 20 0.001* Fail (n = 59) 24 29 6 UFOV results Processing speed Pass (n = 97) 18 55 24 0.02* Fail (n = 26) 13 11 2 Divided attention Pass (n = 59) 10 33 16 0.22 Fail (n = 62) 19 33 10 Selective attention Pass (n = 82) 11 49 22 0.001* Fail (n = 39) 18 17 4 Overall risk category Pass (n = 80) 12 46 22 0.007* Fail (n = 41) 17 20 4 SDSA = Stroke Drivers Screening Assessment. UFOV = Useful Field of View. * P values of < 0.05 were considered significant and indicate an association between rehabilitation physicians’ recommendations and results of off-road assessments.

Stacey R George

To the Editor: We noted with interest the recent publication by Bismark and colleagues1 about complaint-prone doctors in Victoria. This research makes a valuable contribution to the important task of identifying practitioners who are at high risk of delivering poor quality health care. Similar analysis of more than 32 000 complaints received in Queensland from 1992 to 2010 has been undertaken by the Health Quality and Complaints Commission (HQCC). A summary of this work, which was performed in collaboration with the Medical Board of Queensland, was presented recently.2 Between July 2006 and June 2010, only 5% of medical practitioners registered as practising in Queensland were the subject of a complaint in a given year. Medical practitioners with multiple complaints (four or more complaints over the period; 0.7% of all medical practitioners) have substantially more complaints (> 2 SD) than their peers (average number of complaints, 1.6). An analysis of a subgroup of 117 doctors who were each the subject of multiple complaints revealed that they were more likely to be men, to have specialist rather than general registration, and to have an Australian rather than a non-Australian first qualification. Surgeons made up over 40% of this subgroup and were more likely to be the subject of a complaint than were other specialists. Further work is underway to clarify the level of complaints relative to the number of registered practitioners within each specialty. Although there are differences in the samples and analytical methods used in the HQCC study compared with those used by Bismark et al, there are striking similarities in the central findings: a small proportion of doctors produce a disproportionate number of complaints, and past complaint history is predictive of future complaint risk. Health complaints commissions in Australian states are working closely with the Australian Health Practitioner Regulation Agency to explore remedial or preventive opportunities. This task needs to involve the health care industry and professional colleges, as these complaint-prone practitioners are often well known by their colleagues or employers but, equally often, not adequately managed. As there is evidence that unprofessional medical student behaviour predicts both unprofessional doctor behaviour and risk of disciplinary activity,3-4 medical schools should also be engaged in this task.

Matt Vance · Michael Ward · David McKenzie

To the Editor: Were the views expressed by Conway and Savulescu really opposing?1,2 I turned to those pages with much interest, only to find that it seemed as if they would have been in agreement, had you put the scenarios they each describe to both of them. Conway discussed the conflict between doctor and patient about acceptability of the recommended management (the “best interests” of a dying child). In contrast, Savulescu talked of irrational prejudices held by doctors on the grounds of race, sex and other factors. Indeed, unless I missed some subtle points, I could not see any opposition in their arguments. I was, therefore, stumped when your online poll asked me to vote on the question: “Do doctors have the right to refuse certain treatments on the grounds of personal conscience?” Is the question asking about Conway’s point about what the doctor sincerely, on medical grounds, considers to be in the patient’s best interests, or is the question asking about a doctor’s refusal to attend to a patient on the basis of some irrational prejudice? Horses of quite different colours — racing in different races.

Peter C Arnold

Objectives: To determine the long-term mortality pattern of adults with severe traumatic brain injury (TBI), and to identify the risk factors associated with death in this group.Design, patients and setting: Inception cohort study of 2545 adults consecutively discharged from one of three metropolitan tertiary, post-acute inpatient rehabilitation services of the New South Wales Brain Injury Rehabilitation Program from 1 January 1990 to 1 October 2007 after inpatient rehabilitation for primary TBI.Main outcome measure: Survival status at 1 October 2009.Results: 258 deaths were recorded in this sample, yielding a standardised mortality ratio of 3.19 (95% CI, 2.80–3.60). Risk of death remained elevated above societal norms for at least 8 years after discharge from rehabilitation. Mortality risk was increased by: functional dependence at discharge; age at injury; pre-injury drug and alcohol misuse; pre-injury epilepsy; and discharge to an aged care facility. The risk of death from external causes, and respiratory system and nervous system disorders was six to seven times higher, and the risk of death from disorders of the digestive system, and mental and behavioural disorders was five times higher in adults with severe TBI than in the general population.Conclusions: People who survive to discharge from inpatient rehabilitation following a severe TBI were found to have a sustained increase in risk of death for eight years post discharge. Various demographic and injury-related variables selectively increase mortality risk and may be modifiable in order to reduce the observed increase in mortality.

Ian J Baguley MB BS, FAFRM, PhD · Melissa T Nott BAppSc(Hons), PhD · Alison A Howle BSpPath · Grahame K Simpson BSocStud, MA, PhD · Stuart Browne MB BS, MD, FAFRM · A Clayton King MB BS, MD, FAFRM · Rachel E Cotter BA(Hons) · Adeline Hodgkinson MB BS, FAFRM

Objectives: To describe the epidemiology and toxicity of caffeinated energy drink exposures in Australia.Design, setting and subjects: Retrospective observational study analysing data from calls regarding energy drink exposures recorded in the database of an Australian poisons information centre over 7 years to 2010.Main outcome measures: Type of exposure; co-ingestants; symptoms reported; and reported hospitalisations.Results: Callers reported 297 exposures to energy drinks, which showed an increasing annual trend from 12 in 2004 to 65 in 2010. Median age for the 217 subjects with recreational exposure was 17 years (interquartile ratio [IQR], 15–21; range, 11–60) and 57% were male. One hundred recreational users co-ingested other substances, predominantly alcohol (50) or other caffeinated products (44). The number of energy drinks consumed in one session varied greatly (median, 5 units; IQR, 3–8; range, 1–80). Most subjects who reported recreational use reported experiencing symptoms (87%). The most common symptoms were palpitations, agitation, tremor and gastrointestinal upset. Twenty-one subjects had signs of serious cardiac or neurological toxicity, including hallucinations, seizures, arrhythmias or cardiac ischaemia. At least 128 subjects (57 with no co-ingestants) required hospitalisation.Conclusions: Reports of caffeine toxicity from energy drink consumption are increasing, particularly among adolescents, warranting review and regulation of the labelling and sale of these drinks. Educating adolescents and increasing the community’s awareness of the hazards from energy drinks is of paramount importance.

Naren Gunja MB BS, FACEM · Jared A Brown BPharm(Hons), MPH

Objective: To explore the current use of conventional and complementary medicines in Australians aged ≥ 50 years.Design, setting and participants: Cross-sectional postal survey sent to a random sample of 4500 Australians aged ≥ 50 years between June 2009 and February 2010.Main outcome measures: Prevalence of medicines use, reasons for medicines use and sources of medicines.Results: Response rate was 37.3%. Medicines use was very common; 87.1% of participants took one or more medicines and 43.3% took five or more in the previous 24 hours. Complementary medicines were used by 46.3% of participants, 87.4% of whom used both conventional and complementary medicines. The most commonly used medicines were antihypertensive agents (43.2% of participants), natural marine and animal products including fish oil and glucosamine (32.4%) and lipid-lowering agents (30.4%). Doctors recommended 79.3% of all medicines and 93.0% of conventional medicines. Pharmacists commonly recommended occasional medicines (ie, as needed), while friends, family and media most often influenced use of complementary medicines.Conclusions: The use of multiple medicines is common and higher than reported in the 1995 National Health Survey. Today, much medicines use is to prevent future disease by influencing risk factors. High levels of polypharmacy highlight the need to support the safe and effective use of medicines in the community. Although doctors recommend or prescribe most medicines, self-directed medication use is common. This highlights the need for consumer access to accurate information and strategies to improve health literacy about medicines.

Tessa K Morgan BSc, BA, MPH · Margaret Williamson BPharm, MPH, GradDipEpi · Marie Pirotta MB BS, MMed, PhD · Kay Stewart BPharm(Hons), PhD · Stephen P Myers PhD, BMed, ND · Joanne Barnes BPharm(Hons), PhD, MRPharmS

Objective: To determine survival rates of patients with lymphoma in South Australia.Design and setting: De-identified data from the SA Cancer Registry on all patients with lymphoma were analysed, as well as the subgroup treated at the Royal Adelaide Hospital (RAH). For non-Hodgkin lymphoma (NHL), we used the International Working Formulation (IWF) grading. SA and RAH data on survival rates were compared with those for the whole of Australia and the United States.Patients: All patients diagnosed with lymphoma and treated in SA in 1977–2007.Outcome measures: 5-year survival rates for patients with lymphoma, by type of lymphoma and age.Results: Of the total of 8651 patients with lymphoma, 939 were classified as having Hodgkin lymphoma (HL) and 7712 as having NHL. Of those with NHL, 1805 had low-grade, 3576 intermediate-grade, and 510 high-grade NHL. In another 1821 patients, the data were insufficient to make an IWF grading. There was a substantial increase in 5-year survival rates for patients with lymphoma between 1977 and 2007 in SA. While the increase in 5-year survival rates for HL was 7.6 percentage points, survival rates peaked at 88%. For NHL, there was an 18.7 percentage points increase in 5-year survival rates. The first significant increase of 7 percentage points was associated with the introduction of bone marrow transplantation; this was maintained with the increase in 5-year survival rates reaching 14 percentage points by 1995–1999. Since 1999, there has been a further increase of 5 percentage points in 5-year survival rates with the introduction of rituximab.Conclusion: Outcomes in patients with NHL have improved significantly, most likely because of the use of bone marrow transplantation and rituximab. Hospital- and state-based cancer registry data reflect the reality of population outcomes and the impact of new technologies.

Brendon J Kearney FRACP, FRACMA, AM · Luen Bik To MB BS, MD, FRACP · Daniel J Kearney MB BS, FRCPA · David Roder MPH, DDSc · Colin G Luke MB BS, MPH, MD · Ian D Lewis PhD, FRACP · Pratyush Giri FRACP, FRCPA

Objective: To determine current and projected supply, demand and shortfall of medical oncologists (MOs) and the Australian chemotherapy utilisation rate.Design, setting and participants: A 2009 cross-sectional observational study of Australian adult medical oncology practice work patterns.Instrument: Electronic or paper self-administered questionnaire.Main outcome measures: The 2009 and projected (2014) supply, demand and shortfall of full-time equivalent (FTE) MOs, and the chemotherapy utilisation rate.Results: 476 medical oncology positions comprising 234 FTE MOs were identified. Of the 150 medical oncology practices, 117 (78%) were in metropolitan locations and 33 (22%) were in rural locations. The average number of new patients seen per FTE MO was 270 patients (ranging by state from 191 to 343). The demand for FTE MOs was estimated at 326 to 391 in 2009 and 361 to 432 in 2014. The shortfall of FTE MOs was estimated at 92 to 157 in 2009 and 84 to 156 in 2014. The chemotherapy utilisation rate was 19%.Conclusions: The current shortage of MOs is expected to persist in the future. National strategies are needed to increase the capacity of the medical oncology workforce and the chemotherapy utilisation rate.

Prunella L Blinman BMed, FRACP · Peter Grimison MPH, PhD, FRACP · Michael B Barton OAM, MD, FRANZCR · Sally Crossing AM, BEc · Euan T Walpole MB BS, FRACP · Nora Wong BCom/BSocSc · Kay Francis BA(Hons), MA(Hons), MBA · Bogda Koczwara MB BS, FRACP, MBioethics

Objective: To document the prevalence of polycystic ovary syndrome (PCOS) and its associated characteristics in a sample of urban Indigenous women.Design: A cross-sectional survey of Indigenous women, including biochemical and anthropometric assessments. PCOS was assessed using the National Institutes of Health 1990 criteria.Setting and participants: Indigenous women, aged 15–44 years, living in a defined area in and around Darwin, Northern Territory, Australia, September 2003 – March 2005.Main outcome measures: Proportion of participants with PCOS overall and measures of obesity.Results: Among 248 women eligible for assessment, the proportion who had PCOS was 15.3% (95% CI, 10.8%–19.8%). The proportion with PCOS was similar across age groups, but was significantly higher (P = 0.001) in women with a body mass index (BMI) of ≥ 30.0 kg/m2 (30.5%) compared with women with a BMI of 25.0–29.9 kg/m2 (8.2%) or a BMI of < 25.0 kg/m2 (7.0%).Conclusions: A high proportion of these Indigenous women had PCOS. The significant relationship with obesity gives a strong rationale for screening for PCOS during routine care of Indigenous women who are obese and of reproductive age.

Jacqueline A Boyle FRANZCOG, MPH · Joan Cunningham ScD · Kerin O'Dea PhD · Terry Dunbar BBus, MProfEdTraining, PhD Candidate · Robert J Norman MD, FRANZCOG, FRCPA

Objective: To compare three cystic fibrosis (CF) newborn screening strategies used in Victoria since 1989.Design, setting and participants: Retrospective review of newborn screening and clinical records for people with CF born in Victoria between 1989 and 2008 to compare screening strategies: repeat immunoreactive trypsinogen (IRT) testing (IRT/IRT, 1989–1990), IRT and p.F508del mutation analysis (IRT/p.F508del, 1991–2006) and IRT with analysis of 12 CFTR mutations (IRT/12 mutations, 2007–2008).Main outcome measures: Total number of infants screened, people identified with CF (by screening or clinical diagnosis), number of CF-affected terminations of pregnancy, and number of carriers detected.Results: There were 420 people born with CF (live-birth prevalence, 1/3139; 95% CI, 1/2853–1/3462) and 78 CF-affected pregnancy terminations (overall prevalence, 1/2647; 95% CI, 1/2425–1/2896). Of the babies born with CF, 283 (67.4%) were detected by newborn screening alone, 61 (14.5%) had meconium ileus, 33 (7.9%) had a family history of CF, nine (2.1%) were diagnosed antenatally, and 34 (8.1%) were missed by screening (17 missed because IRT level was < 99th percentile, two with repeat IRT level not elevated, 14 without a screened CFTR mutation, and one with missing data). The sensitivities of the protocols were 86.6% for IRT/IRT, 89.9% for IRT/p.F508del, and 95.8% for IRT/12 mutations. Including 12 mutations in the analysis detected one patient who would otherwise have been missed and, had this protocol been implemented from 1989, it would have detected four others.Conclusion: Most babies with CF without meconium ileus, a family history or antenatal diagnosis are detected by newborn screening. Despite improved sensitivity with the 12-mutation analysis, most infants detected would have been diagnosed using the IRT/p.F508del protocol.

R John H Massie MB BS, PhD, FRACP · Lisette Curnow BSc · Judith Glazner RN · David S Armstrong MB ChB, FRACP, MD · Ivan Francis BSc, GradDipCompSc

This is the first reported Australian case of synovial sarcoma of the pharynx. A 29-year-old man had a large hypopharyngeal mass excised and received radiotherapy and chemotherapy. No recurrence was seen 12 months later. Clinical recordA 29-year-old man presented to the emergency department with stridor and a background of progressive globus sensation, loud snoring and worsening dysphagia over 2 years. He had not suffered weight loss, and past medical history was otherwise unremarkable. Flexible endoscopy examination revealed a well circumscribed, encapsulated tumour arising from the left lower lateral wall of the oropharynx and hypopharynx, and from the left arytenoid on its posterior aspect (Box 1). Computed tomography (CT) scanning revealed a 3 × 4.1 cm soft tissue mass arising from the left pharyngeal wall just inferior to the tonsillar fossa (Box 2). Endoscopic laser resection (microlaryngoscopy) was carried out with several scopes, including a bivalved speculum and a Boyle–Davis gag to gain full exposure. The capsule was broken at its deep aspect; however, macroscopic clearance was achieved with dissection down to healthy muscle. The patient made an uneventful recovery and was discharged on Day 3. Histopathological analysis revealed a well circumscribed tumour that measured 8 × 4 × 3 cm and was composed of relatively uniform spindle cells showing frequent mitotic activity. The tumour showed focal necrosis and focal calcification. The posterior surface was raw, suggesting incomplete margins. The cells stained positively for vimentin and CD99, and occasional cells stained positively for cytokeratin AE1/AE3 and epithelial membrane antigen (EMA). Fluorescent in-situ hybridisation (FISH) identified an extra copy of the 5′SS18 signal, suggesting the presence of an unbalanced translocation of the SS18 gene at the 18q11 region. Based on the histological features and FISH results, a diagnosis of monophasic synovial sarcoma was made. Repeat microlaryngoscopy was performed and biopsies of the tumour bed were taken, and histopathological analysis revealed no evidence of residual tumour. Positron emission tomography (PET) and CT staging scans revealed no evidence of regional or metastatic disease. Postoperative radiotherapy was administered to the surgical bed, delivering 60 Gy in 30 fractions over 6 weeks, with bilateral prophylactic nodal irradiation to 50 Gy. After discussion at the multidisciplinary clinic, the patient was administered four cycles of doxorubicin and ifosfamide chemotherapy. Twelve months after the initial diagnosis, there was no evidence of recurrence on endoscopy or PET scan. DiscussionSynovial sarcomas are high-grade soft tissue sarcomas that are thought to arise from pluripotential mesenchymal stem cells.1,2 They account for 10% of all soft tissue sarcomas, and less than 10% occur in the head and neck region.2,3 Since the first case of head and neck synovial sarcoma was described in 1954, there have been fewer than 200 cases reported in the world literature.4 Published cases of synovial sarcoma of the pharynx are rare,5-9 and to our knowledge, this is the first reported case in Australia. There is a male predominance, with a male-to-female ratio of 3 : 2, and although synovial sarcomas can occur at any age, they are most commonly found in patients aged between 25 and 35 years.5,9,10 The neck is the most commonly reported site for primary synovial sarcoma within the head and neck, followed by the upper aerodigestive tract.4 The most typical presentation is a painless mass;2 however, pain, odynophagia, otalgia, bleeding and, in rare cases, pulmonary metastases have also been described. Our patient presented with non-specific upper aerodigestive symptoms, which highlights the importance of a thorough clinical examination. Case reports of pharyngeal synovial sarcomas have found that most patients present within 3 months of the onset of symptoms.5-7 This is in contrast with our patient, who presented after years of loud snoring, progressive globus sensation and eventually stridor. This resulted in a very large tumour almost completely occluding the airway. There are two types of synovial sarcoma, monophasic and biphasic.11 Two-thirds are biphasic, comprising a mixture of elongated basophilic spindle cells and glandular structures made of columnar epithelial cells. Monophasic forms are composed solely of spindle cells or, very rarely, epithelial cells. Monophasic forms are easier to misdiagnose as fibrosarcomas or malignant peripheral nerve sheath tumours, and immunohistochemistry that shows positive reactions for keratin and EMA and FISH can help differentiate these from other sarcomas.1,11 Work-up should include PET and CT scanning of the head, neck and chest to determine the extent of local disease and to search for metastases. The treatment of choice is complete surgical excision with clear margins and adjuvant radiotherapy.4,12-14 For soft tissue sarcomas in general, clear margins have been associated with reduced recurrence and improved survival.12,14 The issue of margin status is particularly important for pharyngeal disease, where attaining wide margins is technically more difficult, and postoperative function for speech and swallowing are important considerations. Postoperative radiotherapy is increasingly recommended as it is associated with reduced local recurrence;4,13,14 however, a survival advantage is yet to be demonstrated. Treatment of the cervical lymph nodes in patients with nodal disease should comprise therapeutic lymph node dissection. There have been no studies on the roles of elective lymph node dissection and prophylactic regional radiotherapy in node-negative patients, and this is an area for future research. The role of neoadjuvant or adjuvant chemotherapy for synovial sarcoma is inconclusive. In a meta-analysis of 14 randomised controlled trials,15 doxorubicin-based chemotherapy was associated with improved recurrence-free survival but not overall survival. A more recent study on ifosfamide-based chemotherapy for synovial sarcomas of the extremities showed an improvement in disease-specific survival.16 As always, the benefits of chemotherapy need to be weighed against the potential significant side effects. Synovial sarcoma is an aggressive disease with a 5-year survival rate of less than 75%.17 There are conflicting conclusions regarding survival among patients with head and neck disease, with some authors reporting a better prognosis for synovial sarcomas of the head and neck compared with the extremities,18 and others reporting a worse prognosis.19 Favourable prognostic indicators include younger age (< 20 years), monophasic subtype, wide excision and, most significantly, smaller tumour size (< 5 cm).3,4 Disease recurrence is a significant problem, with up to 45% of patients with head and neck synovial sarcoma developing a local recurrence and 33% developing distant metastatic disease.4 Further, recurrences occur late, with a mean time to local recurrence of 3.6 years and a mean time to distant recurrence of 5.7 years reported for whole-body synovial sarcoma.17 This highlights the importance of long-term follow-up for these usually younger patients. All patients should initially undergo monthly review, with thorough clinical examination including nasoendoscopy of the pharynx. Where resources permit, patients should also be offered follow-up PET scanning, as this is a sensitive test for detecting recurrent disease. This case represents a rare example of a monophasic synovial sarcoma of the pharynx. Diagnosis and treatment of this disease is difficult, and recurrence is common and occurs late. Prospective studies are required to further elucidate the roles of adjuvant and neoadjuvant radiation treatment and chemotherapy. 1 Endoscopic view of the oropharynx and piriform region There is severe narrowing of the airway at the level of the epiglottis. 2 Sagittal computed tomography image The synovial sarcoma almost completely occludes the laryngeal inlet.

Vikram Balakrishnan MB BS, BMedSc, DipSurgAnatomy · Sam Flatman MB BS, BSc · Benjamin J Dixon MB BS, FRACS · Bernard Lyons MB BS, FRACS

Mackay and Burnet’s Autoimmune diseases, published in 1962, marked the beginning of autoimmunity as a clinical science and led to the future acceptance of the existence of autoimmunity. While there is still controversy regarding the mechanisms of autoimmunity, the authors’ insightful hypothesis based on clonal selection theory and the emergence of “forbidden clones”, due to somatic mutations, is still current, with recent evidence giving further credence to this hypothesis. We salute Mackay and Burnet on the 50th anniversary of this seminal publication. It is particularly pleasing that it has an iconic Australian origin.

Peter J Roberts-Thomson MD, DPhil(Oxon) · Michael W Jackson BSc, PhD · Thomas P Gordon FRACP, FRCPA, PhD

An elderly lady with an interesting clinical history Sydney Hospital, Australia’s oldest hospital, celebrated its anniversary at its present site on Sunday 30 October 2011, 200 years after New South Wales Governor Lachlan Macquarie laid its foundation stone. On Saturday 29 October, many current and former staff, patients, and other people interested in an integral part of Australia’s and Sydney’s history attended an open day and historical exhibition. The story of Sydney Hospital parallels that of Sydney itself — founded in makeshift circumstances to treat convicts, initially dependent on questionable dealings between commerce and government, but eventually establishing itself as a general hospital, serving and supporting a busy and vigorously growing colony and city. Over time, it has moved into providing a somewhat eclectic mix of specialist medical services to both the local Sydney community and New South Wales. Sydney Hospital was founded in 1788 alongside the initial settlement at Sydney Cove. In this case, “founded” meant a series of tents were pitched at the settlement for the medical treatment of convicts and settlers; they were only later complemented by prefabricated buildings brought from Britain by the Second Fleet. In stark contrast to later 19th century, more orderly, attempts at planning for civic improvement and social order, Sydney Hospital simply grew outside of its tents and temporary structures at the harbour foreshore to occupy whatever surrounding buildings were available to meet burgeoning demand.1 A “public–private partnership”, or a rum deal?In 1810, Lachlan Macquarie decided that something had to be done to found a permanent site for the colony’s hospital. The modestly named Macquarie Street was constructed to transport the necessary construction material from the harbour to the hospital site.1 This road was to become a major element of the city plan, eventually featuring almost all of New South Wales’ administrative and governing institutions — which it still does today to a large degree. The building of the hospital turned out to be the genesis of a substantial part of Sydney’s city centre and civic life. The construction of the hospital (which the British government refused to fund) only occurred as a result of Macquarie agreeing to a tender put forward by businessmen Garnham Blaxcell and Alexander Riley in conjunction with the colony’s acting principal surgeon D’Arcy Wentworth. These three individuals — all with an admirable diversification of commercial interests — intended that Macquarie’s need for a permanent colony hospital would be financially lucrative for them. They agreed to build the hospital in exchange for being granted convict labour and a monopoly importation licence for 45 000 gallons (about 200 000 L) of rum.1 As a result of this “public–private partnership”, the “Rum Hospital” — the nickname given by the population, in the Australian tradition of calling a spade a spade — was born. Officially named the Sydney Infirmary, it was eventually called Sydney Hospital from 1881. It was given the Bank of New South Wales’ first account number (00001) — Wentworth owned shares in the bank — and still has this account number, with what is now named Westpac Bank. The building was overly large for the time, prompting questions as to how to use it. It housed not only the wards for convict patients and the surgeons’ quarters, but also, at various times, the Royal Mint, the Legislative Council, the Supreme Court and the Sydney Dispensary, which looked after those who were free but poor, for whom the government had no responsibility.2 It had structural defects from the start, and the centre of the building eventually had to be demolished and rebuilt in the late 1800s. The last of the defects were only uncovered and remedied in a thoroughgoing restoration in the 1980s. Nevertheless, the hospital as an institution survived and expanded. Florence Nightingale, in response to written appeals from the politician and later New South Wales premier Henry Parkes, sent out from Britain her protégé Lucy Osburn and five other nurses (the “Nightingale Nurses”) to establish Australia’s first nursing school on site.3 This was housed in the Nightingale Wing, which opened in 1869 and is the oldest of the existing buildings on the site. Firsts in research and health careSydney hospital has been the site of a number of firsts in medical care in Australia. It hosted the first operation under general anaesthetic (a leg amputation under chloroform) and the first postmortem examination (which appears not to be the same patient). Its staff performed the first x-ray, the first blood transfusion, the first frozen section histopathology, and the first radiotherapy treatment (with radium) in Australia. It was also the place in Australia where a number of specialised surgical procedures were done for the first time — abdominal aortic aneurysm repair, liver transplantation and corrective surgery for cryptophthalmos (this also a world first) being among them. Medical research started with the arrival of the First Fleet. Principal surgeon Dennis Considen investigated the therapeutic properties of native flora, especially eucalyptus.4 However, Australia’s first medical research institute — the Kanematsu Memorial Institute of Pathology — came into being at Sydney Hospital much later, in 1933. The institute was set up with funds from a company that had been founded in 1889 by Fusajiro Kanematsu, the first Japanese merchant to trade with Australia (its Japanese name was not dropped during World War II, underlining Kanematsu’s respected status).5 John Eccles and Bernard Katz worked there in its early days, performing research into the electrophysiological properties of neuromuscular junctions,5 and later separately won Nobel Prizes for Medicine for research into synapse physiology. The hospital and its specialtiesSydney Hospital was also the first in Australia to establish a number of specialised medical units within a hospital — including coronary care, renal, leukaemia, colorectal and melanoma units. The first-ever specialty unit at the hospital, established in 1878, accommodated the “eye beds”. This unit was relocated to Millers Point and then to Woolloomooloo, developing into the Sydney Eye Hospital, which then returned to the original Sydney Hospital site in 1996. It is now the largest eye hospital in the southern hemisphere, providing specialised tertiary and quaternary referral ophthalmological services. The hand surgery unit, still in existence, was the first of its kind in Australia. The Nightingale Wing moved on from being a centre for nurse education to accommodate the Sydney Sexual Health Centre, New South Wales’ largest sexual health service (initially the “Blue Light Clinic”, which treated local sailors). In 1987, the hospital established off-site primary care services in sexual health and HIV medicine at the Kirketon Road Centre in Kings Cross. Sydney Hospital has undergone a long, varied and often haphazard evolution, from tending to scurvied convicts in a tent, to being the first medical institution to bring new kinds of medical care to Sydney and Australia, and to its current role as a provider of a number of specialist services. At the same time, it is the Sydney central business district’s “local hospital”. The founding of the, at the time, grandiose building by Macquarie 200 years ago, predicated on the rum trade, was the catalyst for the establishment of many aspects of health care in New South Wales and Australia. It is an institution deserving of a toast — nowadays, not necessarily with rum — by doctors in Australia. Sydney Hospital on Macquarie Street, circa 1930s Ward 7, Sydney Hospital, circa 1930s Operating theatre, Sydney Hospital, circa 1930s New South Wales Premier Barry O’Farrell views the exhibition, Sydney Hospital: 200 years of care with exhibition curator Jennifer Sanders during the Sydney Hospital Bicentenary Community Open Day

Astika K Kappagoda BA(Hons), MB BS, PhD

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This is a compelling read. Dr Jayant Patel arrived at Queensland’s Bundaberg Hospital on April Fools’ Day 2003 and, in the words of former Federal Health Minister Michael Wooldridge, “walked into an environment tailor-made for disaster to occur”. In June 2010, he was sentenced to seven years’ imprisonment for manslaughter and grievous bodily harm involving four patients operated on in Bundaberg. An appeal was dismissed. The authors of this well documented account are eminently qualified to tell the tale — Professor Dunbar teaches clinical governance and risk management at Flinders University in Adelaide, Professor Reddy is a health and organisational psychologist at Flinders and Stephen May is a former psychologist and journalist. As they explain, Patel was far from being the only one at fault. The authors carefully examine the bureaucratic structures and attitudes in existence in Queensland Health, and the personal and professional failings of particular administrative staff at the Queensland Medical Board and the hospital that led to Patel — whose registration as a specialist surgeon was restricted in two US states — being appointed as director of surgery at Bundaberg. They find that the hospital was “fiscally driven”, and Patel’s ability to perform large numbers of operations benefited the budget and completely overrode concerns about patient outcomes. The gulf between management and clinicians is neatly encapsulated in the story of an administrator telling a senior Bundaberg clinician concerned about Patel’s activities: “You have to understand that this is a business.” To which the doctor replied: “That’s where the problem is, you see. I think it’s a hospital.” The efforts of this clinician and many other staff, patients and relatives to achieve justice are well described, as are the findings of the numerous formal inquiries and the details of Patel’s trial. Patel’s earlier life and medical training have been meticulously researched and the authors have attempted to give a balanced view, pointing out that many of the 1000 patients he operated on at Bundaberg benefited from his surgery. Had the proper checks and balances been in place, the negative outcomes might never have occurred. Has the Queensland public health system learnt from the Patel case? Sadly, the authors conclude that it has not — their final sentence warns that a case like Patel’s “could be happening right now in your own modern overburdened healthcare system”.

Caroline M de Costa

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This account of the lead-up to the 2010 trial of Jayant Patel — dubbed “Dr Death” by the media — is excellent, which is not surprising considering Professors Dunbar and Reddy’s background in health services implementation research at Deakin University, Victoria. Unfortunately, the same can’t be said for the authors’ coverage of the real impact of the Patel case on health regulation in Australia. The Australian Health Practitioner Regulation Agency (AHPRA) is mentioned only to record its establishment in July 2010. Missing is any reference to the Health Practitioner Regulation National Law Act (enacted in Queensland in 2009 and in the other states in 2010), which came into existence before the AHPRA and started to make it extremely difficult for a similar situation to occur today. The reader is left with the impression that little has changed and similar tragedies could occur today. But while there are no guarantees that a rogue doctor can no longer be appointed, regulation has changed radically since then. Today, complaints from doctors and the community are not so much about the cursory checking of international medical graduates’ qualifications but about the AHPRA requiring too much information. Patient safety is an explicit principle underpinning the National Health Practitioner Regulation Law, which created the Medical Board of Australia and the AHPRA. The authors fail to mention the new mandatory reporting laws that require health professionals to report those who place the health and safety of patients at risk. However, the facts about the Patel case provided in this book should be interesting for those new to regulation and clinical governance.

Merrilyn Walton