Volume 197 Issue 10

From 1 December 2012, Australia will be the first country in which plain packaging is mandatory for all tobacco products: celebrating a stunning success for public health.

Mike Daube BA(Hons), HonDSci · A Rob Moodie MB BS, MPH · Simon Chapman PhD, FASSA

Public and private payers, professional bodies and government agencies are now engaged in identifying “low-value” health care practices that should no longer be funded. The challenge in this is to develop evidence-based, transparent methods for undertaking this process, that are sensitive to the needs and concerns of patients and clinicians.

Ian A Scott MB BS, FRACP, MHA

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

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

Is it ethical, moral and feasible to release gamete donors’ medical records to conceived offspring?This year, the Law Reform Committee of the Parliament of Victoria released recommendations from an inquiry into various aspects of donor conception, including the ability of donor-conceived people to access identifying and medical information about their donors.1 The Committee recommended that donor-conceived people gain retrospective access to such information, similar to ...

Damian H Adams BBiotech(Hons)

Good working relationships with journalists are needed during public health crises but many journalists believe that health departments could do a better job of meeting their information needs, both in content and timeliness.

Melissa A Sweet BA, MA · Kate E Holland PhD · R Warwick Blood PhD

The overt role of journalists is to provide information to an interested or concerned public. But journalists also have a shadow role — generating entertainment value to enhance advertising and shareholder revenue. Likewise the overt role of public health officials is to disseminate accurate, timely information to inform an interested populace; but health officials too have a shadow role — to minimise the political risks of the elected branch of government

Craig B Dalton BMed, MMSc, FAFPHM

To the Editor: We write to express our concerns with the article by Runciman and colleagues on the appropriateness of health care delivery in Australia.1 Our concerns focus on the issue of stroke care and the notion that poor compliance with guidelines is interpreted as “inappropriate” patient care. This study did not measure hard clinical end points, such as stroke recurrence, when evaluating the appropriateness of ...

Thanh G Phan · Velandai K Srikanth

To the Editor: The article by Runciman and colleagues1 has attracted much interest within the profession and in the lay press. However, there are serious methodological flaws in their study. The first issue is with the choice of clinical guidelines for assessing patient care. Although we have evidence for what is “best” practice in some areas, we are lacking this evidence in others. Hence, many of ...

Sean Mackay

To the Editor: The CareTrack study1 has produced considerable debate that has mostly focused on its aggregated findings about compliance with appropriate health care delivery. There needs to be much wider discussion, not about the aggregate figure, but about the variation, such as the 39 health care providers for whom compliance varied between 32% and 86%. Such unwarranted variation in health care has been identified elsewhere ...

Paresh Dawda

In reply: The CareTrack Australia study1 has received support for its general recommendations, but also some criticism. Here, we address the issues raised by commentators. Levels of evidence: Phan and Srikanth, and Mackay join previous commentators2,3 in calling into question the key CareTrack finding — that adult Australians received appropriate care at 57% of eligible health care encounters in 2009 and 20101 — because 71% of indicators ...

William B Runciman · Tamara D Hunt · Natalie A Hannaford · Peter D Hibbert · Johanna I Westbrook · Enrico W Coiera · Richard O Day · Diane M Hindmarsh · Elizabeth A McGlynn · Jeffrey Braithwaite

The risks to the future child of morbidity associated with birth outside a hospital setting — largely ignored to date — need to be better quantified and communicated.

Lachlan J de Crespigny · Susan P Walker · Julian Savulescu

To the Editor: A major achievement of the National Immunisation Program is the progress towards elimination of congenital rubella syndrome and interruption of endemic rubella transmission in Australia.1 However, some population subgroups remain at risk of rubella infection. We describe a workplace outbreak in Perth in 2011. Between 30 June and 6 July 2011, three employees of the same organisation working in an open area on a single ...

Teresa M Ballestas · Suzanne P McEvoy

Some facilities in the United States have enforced a mandatory influenza vaccination policy with punitive action for noncompliance, resulting in sustained vaccination rates of above 97%.

Vivian K Y Leung · Susan E Harper · Monica A Slavin

To the Editor: Refugee health is an emerging area of clinical care. Over 200 000 humanitarian entrants have settled in Australia over the past 15 years, and the annual humanitarian intake has recently increased to 20 000 people.1 While there is (delayed) information on post-arrival refugee health screening, little is known about the longitudinal outcomes or use of health services in refugee-background Australians, and they remain invisible in existing population ...

Georgia A Paxton · Margaret P Kay · Ignacio Correa-Velez

To the Editor: Our scepticism about the value of many of the burgeoning number of clinical guidelines is reinforced by the position statement on vitamin D and health for adults.1 It was surprising not to find an explicit statement that there is Level I evidence that vitamin D monotherapy does not prevent falls2 or fractures3 or reduce mortality.4 Instead, Nowson and colleagues conclude that “there ...

Mark J Bolland · Andrew Grey · Tim Cundy

In reply: Our position statement summarised findings from the most relevant peer-reviewed literature.1 We clearly acknowledged that there are inconsistencies in the literature, as is often the case in many fields of medicine. Most Level I evidence indicates that vitamin D (combined with adequate calcium) reduces falls and fractures in older people. Mortality is also reduced.2 The combination of vitamin D supplementation with adequate calcium does ...

On behalf of the Working Group of the Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia

To the Editor: Duckett makes a compelling argument for introducing non-pay for non-performance.1 However, such a scheme will not produce discernible results, for two reasons. First, interventions such as “time out” and surgical checklists have proven successful in reducing rare but clearly defined events, such as wrong-site surgery and retained foreign bodies.2 Not paying when these errors occur will have no impact on efforts to reduce ...

Sue M Evans · Peter A Cameron · John J McNeil

In reply: Evans and colleagues present their critique of my proposition1 to use incentives based on adverse events recorded in routine data as an alternative — it is not. Routine data, audits and registries all have a place in the quest to improve safety of care in hospitals. The financial impact of non-pay for non-performance may be small. However, early evidence from the United States suggests ...

Stephen J Duckett

Using a multiplatform approach, the authors identify 156 potentially ineffective and/or unsafe services listed on the Australian Medicare Benefits Schedule that warrant further consideration. Reducing the use of existing services that offer little or no benefit relative to the cost of their public subsidy would allow funding to be reallocated to more beneficial or cost-effective services.

Adam G Elshaug MPH, PhD · Amber M Watt MPH · Linda Mundy MPH · Cameron D Willis PhD

Data collected before and after the H1N1 2009 influenza pandemic indicate significant shifts in public threat perception and anticipated response to a future pandemic. The H1N1 2009 pandemic has altered public perceptions of the probability of a pandemic in the future, but has left the public feeling less vulnerable.

Melanie R Taylor BSc(Hons), PhD, CPsychol · Garry J Stevens BSc(Hons), MClinPsych · Kingsley E Agho MSc, MPH, PhD · Sheree A Kable BMed, PhD · Beverley Raphael MB BS, MD, FRANZCP

Non-melanoma skin cancer treatments increased by 86% between 1997 and 2010. The authors anticipate that the number and the total cost without inflation of non-melanoma skin cancer treatments will increase by a further 22% between 2010 and 2015.

Marloes Fransen MB BS · Amalia Karahalios BSc, MPH · Niyati Sharma MB BS · Dallas R English BSc, MSc, PhD · Graham G Giles BSc, MSc, PhD · Rodney D Sinclair MB BS, MD, FACD

Objectives: To measure the frequency and content of electronic handover before and after implementation of the Blue BARRWUE handover system, and to measure its effect on patient safety and hospital efficiency over weekends.Design, setting and participants: Point-prevalence study comparing outcomes for general medical inpatients present over weekends before implementation (1 May 2008 to 30 April 2009) and after implementation (1 May 2009 to 30 April 2010) of ...

Boloor S Rao MB BS, DNB · Gail O Lowe RN, BN, MHA · Andrew J Hughes MB BS, FRACP

H1N1-containing vaccines were not statistically associated with Guillain-Barré syndrome, but this study could not exclude smaller increases in the relative incidence. Active surveillance of adverse events following immunisation is required to maintain public and health care professional confidence in mass vaccine implementation programs.

Nigel W Crawford MB BS, MPH, PhD · Allen Cheng MPH, PhD, FRACP · Nick Andrews MSc · Patrick G Charles MB BS, PhD, FRACP · Hazel J Clothier MAppEpid, MscID, FIBMS · Bruce Day MB BS · Timothy Day MB BS · Peter Gates MB BS · Richard Macdonell MB BS · Les Roberts MB BS · Victoria Rodriguez-Casero MB BS · Tissa Wijeratne MB BS · Lynette Kiers MB BS

Using cases as their own controls potentially provides stronger evidence for analysing adverse events following vaccinationMMaintaining public confidence in vaccines requires having effective postmarketing vaccine safety surveillance systems in place to rapidly address emerging concerns about vaccine safety. However, conducting studies of vaccine safety presents several challenges for traditional observational study designs. Important differences may exist between vaccinated and unvaccinated individuals that could confound the ...

Steven Hawken MSc · Kumanan R Wilson MD

Complex challenges call for action inside and outside the health care box. Inside the box, health workers can manage hypertension and diabetes and beat tuberculosis. But they need support from outside the box — leadership and adequate tools for their work.

Ian Maddocks MD, FRACP, FAChPM

For those who work in conditions of abundance, what should inform our practice are the memories of crying need, unmet. By failing to internalise the lessons of working in needy areas, and continuing to work in a bubble, we fail our unseen fellow man.

Ranjana Srivastava MB BS(Hons), FRACP

The clinic of the Sudan Medical Relief Project (www.sudanmedicalrelief.org) is in Old Fangak, in what is now the Republic of South Sudan. In 2010, I spent 7 weeks working there with an American medical team, before being evacuated owing to increasing violence in the area. We flew with one backpack each from Lokichoggio, on Kenya’s border, into South Sudan. Our plane was a twin-engined Cessna with an ...

Benjamin H M Hunn BMedSc(Hons)

Health workforce governance: improved access, good regulatory practice, safer patients. Stephanie D Short, Fiona McDonald, editors. Farnham, UK: Ashgate Publishing, 2012 (xix + 272 pp, $110). ISBN 9781409429210. ENSURING THAT we produce a health workforce that is well trained, “fit for purpose”, equitably distributed, and that delivers effective and safe health care is a key responsibility of all those involved in medical education, health governance and health policy making. Various health scandals have drawn the attention of the public to failures in health governance, and raised considerable doubt about the ability of the health professions (and in particular doctors) to self-regulate in a way that will protect the public. This ambitious academic text seeks to link the “three pillars” of health workforce governance: access to health services; regulation of health service providers; and patient safety and quality of care. The book is edited by experienced Australian academics with backgrounds in health economics and law, respectively, and its scholarly tone reflects this. Contributors have been deliberately selected by the editors from a wide range of disciplines, and comprise academics, regulators and health professionals from Australia, Canada and Indonesia, both well known and less well known. While the major focus of the text is Australian, some chapters describe examples drawn from the Indonesian and Canadian contexts — these would have been more useful if their relevance to health workforce governance in the Australian context had been made more explicit or, alternatively, if the whole text had a more clearly articulated global focus. Although this disciplinary variability is promoted as a strength, it does produce chapters that vary dramatically in approach and relevance. The book is divided between chapters that are a pleasure to read (and take notes from) and those that focus on describing micro-policy changes and leave the reader with a sense of frustration and many questions unanswered. While this is a book of great relevance to scholars interested in health workforce and governance and there are some outstanding chapters, the patchy quality overall and lack of a coherent narrative linking the chapters limits its relevance for a broader audience.

Sarah L Larkins

Other doctors may not know exactly what they do, but sexual health physicians love the diversity of their work

Karen Burge

Dr Carole Khaw is a senior registrar in her final year of advanced training in sexual health medicine, working part-time at Clinic 275, STD Services at the Royal Adelaide Hospital. She is also a clinical skills lecturer at the University of Adelaide

Cate Swannell

Dr Darren Russell is Director of Sexual Health at Cairns Base Hospital, Adjunct Associate Professor at James Cook University School of Medicine and Clinical Associate Professor in population health at the University of Melbourne. He is also past-president of the Australasian Chapter of Sexual Health Medicine and the Australian Federation of AIDS Organisations.

Interview by Karen

A Newcastle general practitioner gives his spin on the health and environment benefits of biking

Sophie McNamara

Navigating the finances of car ownership

Amanda Bryan