Volume 198 Issue 11

Contrary to common rhetoric, general practice-type patients do not significantly contribute to ED congestion or burden. And it is usually more appropriate for patients to seek immediate care in the ED rather than visit a general practitioner.

Gerard J FitzGerald MD, FACEM, FRACMA · Ghasem Toloo BA, MA, PhD

Assessing the outcomes of homebirths attended by qualified professionals within a well regulated environment is an important part of shedding light on this debate.

Marc J N C Keirse MD, DPhil, FRANZCOG

When children with rare chronic diseases grow up, it’s often a rocky pathway to adult care.

Yvonne A Zurynski BAppSc, MAppSc, PhD · Elizabeth J Elliott MD, MPhil, FRACP

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

Samantha C Burnham · Victor L Villemagne · S Lance Macaulay

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

Despite some promising first steps, there is still much to do in the areas of workforce, payment reform, innovation in e-health, and performance measurement.

Claire L Jackson MB BS, MD, FRACGP

Will replacing the outdated Inebriates Act 1912 with the new Drug and Alcohol Treatment Act 2007 enable better management of people with severe substance dependence?

Glenys M Dore MB ChB, FRANZCP, FAChAM · Robert G Batey FRACP, FRCP(UK), FAChAM · Darren J Smyth BA(Nursing), BA(Anthropology), GradDipHlthEd

It’s not as simple as new for old: we need to follow a process for “disinvestment” in existing medical procedures, services and technologies Criteria have been developed for assessing the safety, effectiveness and cost-effectiveness of new and emerging health interventions, but additional challenges exist in identifying opportunities for reducing the use of existing health technologies or procedures that are potentially overused, (cost-)ineffective or unsafe.1 Criteria have been proposed to flag technologies that might warrant further investigation under quality improvement programs.1 These criteria are: new evidence becomes available; there is geographical variation in use; variation in care between providers is present; the technology has evolved and differs markedly from the original; there exists a temporal trend in the volume of use; public interest or controversy is present; consultation with health care workers and funders raises concerns; new technology has displaced old technology; there is evidence of leakage (use beyond the restriction or indication); the technology or intervention is a “legacy item” that has never been assessed for cost-effectiveness; use is not in accordance with clinical guidelines; or the technology is nominated by clinical groups. After such a nomination was made by members of the clinical laboratory community regarding vitamin B12 and folate tests, we sought to determine whether these tests met other criteria. We hope that this article will encourage debate and discussion about the appropriate use of these tests. Testing for vitamin B12 and folate deficiencyDiagnosing vitamin B12 and folate deficiencies is difficult. The symptoms are diverse (such as malaise, fatigue and neurological symptoms), as are the signs (including megaloblastic anaemia and cognitive impairments). Defining target conditions is, therefore, also difficult. Tests include a full blood count and blood film examination, serum B12, serum folate and red-cell folate (RCF) assays, as well as examination of metabolic markers such as methylmalonic acid (MMA) and homocysteine (Hcy). Untreated vitamin B12 deficiencies may cause serious health problems, including permanent neurological damage (which may occur with low serum B12 levels without haematological changes). Maternal folate deficiencies have been associated with neural tube defects in infants. Potential vitamin B12 or folate deficiencies therefore need to be appropriately investigated and managed. New evidenceThe utility of a diagnostic test is influenced in part by its precision (the ability of a test to faithfully reproduce its own result) and its diagnostic accuracy (ability to discriminate between a patient with a target condition and a healthy patient). Evidence suggests serum B12 tests have poor discriminative ability in many situations, and debate is ongoing over which folate assay is most useful. The only systematic review and meta-analysis of the diagnostic accuracy of serum B12 tests (conducted by members of our group) suggested that these tests often misclassify individuals as either B12 deficient or B12 replete.2 These findings are consistent with other reports in the literature. One recent report states: Both false negative and false positive values are common (occurring in up to 50% of tests) with the use of the laboratory-reported lower limit of the normal range as a cutoff point for deficiency.3 And further: There is often poor agreement when samples are assayed by different laboratories or with the use of different methods.3 Widespread CBLA (competitive-binding luminescence assay) malfunction has also been noted, with assay failure rates of 22% to 35%4 (interference due to intrinsic factor antibodies may explain some of this variation). While a critical overview has suggested that “falsely normal cobalamin concentrations are infrequent in patients with clinically expressed deficiency”, the author notes challenges in diagnosing subclinical deficiency5 (mild metabolic abnormalities without clinical signs or symptoms). Assessment of this evidence base is complicated by the lack of a universally accepted gold standard and by target conditions that are difficult to define, variable clinical presentations and variable cut-off values used to define deficiency. For investigating folate status, RCF assays are thought to be less susceptible to short-term dietary intake than are assays for serum folate. However, it has been reported that: The red cell folate assay is more complex to perform than the serum folate assay and requires more steps in sample handling before analysis, and this may be one of the reasons why the precision of the red cell folate assay is less than that of the serum folate assay.6 As discussion continues over which folate test is preferable, new evidence related to the prevalence of folate deficiencies in countries with mandatory food fortification has shifted the focus toward whether there is a need to perform any folate investigations in these jurisdictions. In Australia, mandatory fortification of wheat flour with folic acid was introduced in September 2009.7 Prevalence estimates from a sample of inpatients and outpatients suggested that folate deficiency stood at 0.5% in April 2010, showing an 85% reduction in absolute numbers since April 2009.7 While there is currently no evidence to suggest that the prevalence of megaloblastic anaemia caused by folate deficiency has been reduced, the low frequency of low serum RCF test results in countries where there is mandatory fortification of grain products with folic acid supports the perspective that “there is no longer any justification in ordering folate assays to evaluate the folate status of the patients”.8 Technology developmentOver time, multiple technologies for analysing vitamin B12 status have become available, including assays for measuring holotranscobalamin (holoTC, the bioavailable form of vitamin B12), as well as metabolic markers such as MMA and Hcy.3,5 However, like all tests, these are imperfect: holoTC is expensive, not routinely available, itself reliant on poorly defined serum B12 reference ranges, and is yet to be confirmed as a superior test to the serum B12 assay.5 Hcy measurement is subject to artefactual increases due to collection practices, and reference ranges are variable. The availability of MMA tests is restricted to some clinical and research laboratories. As a result, the optimal procedure for measuring vitamin B12 is unclear. As noted above, while a number of approaches exist for assessing folate status, there is currently no consensus on the most appropriate laboratory investigation process. Temporal, geographical and provider variationsAustralian Medicare utilisation data have shown substantial growth in the use of item 66602, which relates to the combined use of serum B12 and folate tests. Between the financial years 2000–01 and 2009–10, use increased from 1082 services per 100 000 population to 7243 services per 100 000 population (21.78% average annual growth rate).9 Over the same period, spending on pathology services overall grew at an average annual rate of 6.3%. Geographical variation was also present, with the number of services reimbursed for item 66602 ranging from 1962 per 100 000 population in the Northern Territory to 8658 per 100 000 population in the Australian Capital Territory in 2009–10.9 While some of this variation may be due to demographic differences and populations known to have access to fewer health services (eg, Indigenous Australians), the substantial temporal and geographical differences in use raise more questions about appropriate use of these tests, and whether or not they are underused or overused. GuidelinesGuidelines related to the use of vitamin B12 and folate tests vary widely in their recommendations. While some recommend B12 and folate tests as screening tools in commonly encountered illnesses such as dementia, others suggest restricting testing to patients who have already undergone pretest investigations (such as full blood examinations; however, we note that neurological damage may occur in patients with low serum B12 levels and without haematological changes).10,11 Guidelines may differ on key recommendations, such as the preferred first-line investigation for establishing folate status, while some question the utility of folate investigations at all in jurisdictions where food is fortified with folate.12-14 LeakageWith wide variability in guideline recommendations, and with few appearing to consider the diagnostic accuracy of B12 or folate tests, determining the extent to which services have “leaked” beyond their clinical indications is difficult. Possible leakage is evidenced by the use of serum B12 tests among patients presenting with weakness and tiredness, which is not supported by any available guidelines.15 A large study of general practitioners indicated that between April 2000 – March 2002 and April 2006 – March 2008 their use of serum B12 tests among patients presenting with weakness and tiredness increased by 105%.15 DiscussionTests for investigating patients’ vitamin B12 and folate status have become widely used in clinical practice. Yet existing evidence suggests that the diagnostic accuracy of serum B12 tests is difficult to determine and may be highly variable. While other tests are available for investigating suspected B12 and folate deficiency (such as holoTC, MMA and Hcy), the diagnostic accuracy of these tests is also contested. Challenges in examining the diagnostic accuracy of serum B12 tests include highly variable clinical presentations, lack of a gold standard and inconsistent cut-off values used to define deficiency. While it remains under debate whether the serum or red-cell folate test is most useful for investigating folate status, mandatory folate fortification in Australia may call into question any use of these tests. Temporal variation in use and geographical differences in how these tests are employed are both evident in Australian data. Moreover, available clinical guidelines are highly inconsistent in their recommendations. Collectively, the issues of test accuracy, wide variability in test use, and inconsistent guideline recommendations suggest that the use of vitamin B12 and folate tests is an area with much scope for quality improvement. To improve the use of these tests, further assessment is needed that examines the complexity associated with clinical decision making and the various factors influencing why doctors request these tests. The decision to request an investigation such as a B12 or folate test may be driven by a range of factors, including ease of use, cost, absence of significant patient risk, the perceived need to respond to patient requests, lack of appreciation of the diagnostic accuracy of the tests, or ready availability of results.16 Understanding how these factors influence the use of B12 and folate tests may best be achieved through direct consultation with general practitioners, pathologists, specialists and consumers and is a critical step in advancing the assessment of these tests.

Cameron D Willis PhD · Michael P Metz MD · Janet E Hiller MPH, PhD · Adam G Elshaug MPH, PhD

Clinicians need to consider analytical issues when requesting and interpreting these testsVitamin B12 and folate tests are useful for identifying patients with a deficiency. In this issue of the Journal, Willis and colleagues highlight some of the limitations of serum vitamin B12 assays.1 They also emphasise the uncertainty regarding whether red-cell or serum folate should be the preferred first-line test for folate status. The issues underlying ...

Christopher-John L Farrell MB BS, FAACB, FRCPA

Our immunisation incentive system has helped us achieve high levels of childhood immunisation. Will recent changes continue to support these levels?

Kirsten Ward BHlthSc(PublicHealth), MPH(Hons) · Brynley P Hull BSc(Hons), MPH · Julie Leask PhD, MPH

Punishing on-call and after-hours arrangements are threatening Australia’s rural medical workforce.

Chee S Koh

Removing the Medicare rebates for telehealth in outer metropolitan areas is a short-sighted policy.

Victoria A Wade

To the Editor: McIntyre and Oats promote the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for gestational diabetes mellitus (GDM) as being well reasoned.1 Derived from observational data and mathematical modelling in an attempt to provide a worldwide definition and to improve outcomes, these criteria will significantly increase the number of women diagnosed with GDM2 in health care systems that have ...

Adrian V G Taylor

To the Editor: McIntyre and Oats1 suggest that Australian medical practitioners should adopt the new International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria for the management of gestational diabetes mellitus (GDM),2 mainly because of the findings of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study.3 If adopted, a significant number of women will be diagnosed with GDM if their only blood ...

Michael C d’Emden · Narelle D Fagermo · Amanda J Love · Karin M C Lust

In reply: Taylor welcomes a strong evidence base for clinical practice, which is echoed by d’Emden and colleagues. However, their strong support for the current Australian diagnostic criteria for gestational diabetes mellitus (GDM) is surprising, given that these criteria are the product of an “Ad Hoc Working Party” report.1 This guideline, published in 1991, clearly acknowledged a lack of strong evidence and advocated criteria that ...

H David McIntyre · Jeremy J N Oats

To the Editor: Moynihan has recently suggested that gestational diabetes mellitus (GDM) is a “non-entity”1 and cited controversy regarding new diagnostic criteria, while McIntyre and Oats have defended the practice of screening for GDM.2 Robust data associate hyperglycaemia with adverse pregnancy outcomes;3 and randomised controlled trial data show a beneficial effect of screening and treatment on perinatal outcomes.4 However, it is short-sighted to consider only the ...

Mark McLean · Len D Moaven · Naswrin Moin · Jennifer A Bradford

To the Editor: We read the recent study by Elshaug and colleagues1 with interest, but were concerned by the inclusion of radiotherapy for spinal cord disease as a potentially low-value intervention. The lack of clinical review in the identification process appears to be the key driver in coming to this erroneous conclusion. Elshaug and colleagues recognise the need for clinical expertise in assessing trials demonstrating no ...

Andrej Bece · Christopher Hamilton · Brigid E Hickey

To the Editor: Elshaug and colleagues recently attempted to identify low-value health care practices.1 They further identified 13 services found by more than one of their search methods, implying that these services may be of particularly low value. One such practice identified is “radiotherapy for patients with metastatic spinal cord disease”.1 However, this terminology is loose at best, and the following quotes from Elshaug et al’s own ...

Graham Pitson

In reply: I thank Bece and colleagues and Pitson for engaging constructively with this quality improvement agenda. Bece et al challenge the inclusion of radiotherapy for spinal cord disease in our list of 150 candidate treatments potentially warranting further review under a quality improvement program.1 Pitson calls attention to “loose terminology” in the same example. This latter point, I concede. Precision of language in relation to ...

Adam G Elshaug

A review of case notes from our Sydney-based paediatric allergy services, between 1 January 2003 and 31 December 2011, identified 74 children who had been prescribed diets that eliminated foods containing natural salicylates before attending our clinics. The most common indications for starting the diets were eczema (34/74) and behavioural disturbances (17/74) including attention deficit hyperactivity disorder (ADHD). We could find no peer-reviewed evidence to support the efficacy of salicylate elimination diets in managing these diseases. We do not prescribe these diets, and in a survey of European and North American food allergy experts, only 1/23 respondents used a similar diet for eczema, with none of the respondents using salicylate elimination to treat ADHD. A high proportion (31/66) of children suffered adverse outcomes, including nutritional deficiencies and food aversion, with four children developing eating disorders. We could find no published evidence to support the safety of these diets in children. While this uncontrolled study does not prove a causal relationship between salicylate elimination diets and harm, the frequency of adverse events appears high, and in the absence of evidence of safety or efficacy, we cannot recommend the use of these diets in children.

Paul E A Gray Mb Chb, FRACP, FRCPA · Sam Mehr MB BS, FRACP, FRCPA · Constance H Katelaris MB BS, PhD, FRACP · Brynn K Wainstein MB ChB, FRACP, PhD · Anita Star BHlthSc, PhD, APD · Dianne Campbell MB BS, FRACP, PhD · Preeti Joshi MB BS, FRACP, PhD · Melanie Wong PhD, FRACP, FRCPA · Brad Frankum BMed(Hons), FRACP · Karuna Keat MB BS, FRACP, FRCPA · Geraldine Dunne BSc(Hons), RN · Barbara Dennison DipCommNut, ANAPD · Alyson Kakakios MB BS, FRACP · John B Ziegler FRACP, MD, FAAAAI

With suitable guidance and monitoring, dietary modification is safe and can improve quality of lifeSalicylates are a diverse family of 2-OH benzoic acid derivatives produced in all plants. The parent molecule, salicylic acid (SA), is a ubiquitous phytohormone responsible for pathogen resistance, regulation of growth, and a wide variety of other biological functions.1,2 The medicinal use of salicylate-containing plant extracts was first recorded about 3500 years ...

Robert H Loblay MB BS, PhD, FRACP · Velencia L Soutter MB BS, FRACP · Anne R Swain PhD, APD

Introducing the MJA’s new Cardiology series, which aims to review current and future challenges and innovations in cardiac care.

Derek P B Chew MB BS, MPH, FRACP · Ian A Scott MB BS, FRACP, MHA

Moving away from managing isolated risk factors towards assessment and management of absolute cardiovascular disease risk will target the patients most in need of medication and avoid medicalisation of the low-risk population.

Mark R Nelson MB BS(Hons), FRACGP, PhD · Jennifer A Doust BM BS, FRACGP, PhD

Three of the four methods used to calculate general practice-type patient attendances at EDs estimate that these patients account for 10%–12% of attendances and less than 5% of the total length of stay in the EDs of Perth’s major hospitals. The fourth method, used by the Australian Institute of Health and Welfare, estimates these attendances at about 25%, raising the question of whether it is an overestimate.

Yusuf Nagree MB BS, FACEM, MBA(E) · Vanessa J Camarda · Daniel M Fatovich MB BS, FACEM, PhD · Peter A Cameron MB BS, MD, FACEM · Ian Dey MB BS, FACEM · Andrew D Gosbell PhD · Sally M McCarthy MB BS, FACEM, MBA · David Mountain MB BS, FACEM

A retrospective analysis of the outcomes for women who planned a homebirth and their babies provides the first national evaluation of publicly funded homebirth in Australia.

on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium

A study of the behaviour and perceptions of parents of food-allergic children finds that many parents are complacent about precautionary labelling on packaged foods, even if their children have a history of anaphylaxis.

Giovanni A Zurzolo BBioMedSc(Hon) · Jenifer J Koplin PhD · Michael L Mathai PhD · Mimi K L Tang PhD, FRACP · Katrina J Allen PhD, FRACP

A study of disease notifications in general practice seeks to answer the question of whether increases in pertussis notifications in Australia since 2008 were due to a true increase in the disease or an increase in testing.

Marlena C Kaczmarek BSc, MPH · Lisa Valenti BEc, MMedStat · Heath A Kelly BSc, MB BS, MPH · Robert S Ware BSc(Hons), PhD · Helena C Britt BA, PhD · Stephen B Lambert MAppEpid, FAFPHM, PhD

A challenging case of acute febrile illness and rapidly evolving petechial rash and digital gangrene in a traveller returning from North India and Nepal.

Puvesh Punj MB BS · Renjy Nelson MB BS, FRACP · Sarah Gardiner BM BS · Michelle Lodge MB BS, FRACS · Stephen R Graves FASM, FRCPA, PhD · Morgyn S Warner MD, FRACP, FRCPA

Family stories provide the key to understanding the patient’s wishes and open doors to plain speaking, in this reflection on caring for a woman who is unable to communicate.

Matthew J Links MB BS, PhD, FRACP · Theodora Bikou BSW

Telehealth could enable real-time interactions between registrars, patients and remote supervisors, and create medical training places in outback Australia

Susan M Wearne MMedSc, FRACGP, FACRRM

MY CAREER choice was based on non-fiction reading as a teenager. Starting with American journalist Berton Roueché, who adapted material from the terse Morbidity and Mortality Weekly Report covering investigations by the US Centers for Disease Control, I have been reading popular accounts of epidemics for a while.And epidemics fascinated the earliest writers: pestilence as one of the horsemen of the Apocalypse in the Bible; ...

Charles S Guest

Frank Bell was an outstanding orthopaedic surgeon, known for his strong work ethic, forthright nature and integrity, and excellent teaching and mentoring. Frank was born on 6 July 1926, the third of five children of Maston and Bessie Bell. He spent his childhood on the family’s 2-acre property in Mount Lawley (now an inner suburb of Perth). His daily chores included helping at the Albany Bell chicken ...

Kathryn Stark

Telehealth is beginning to gather momentum in private practice. How are those already connected making it work?

Annabel McGilvray

Anglican Overseas Aid and Hadassah Australia are involved in a unique interfaith project improving health care for Palestinians.

Cate Swannell

THE Chief Minister of the Australian Capital Territory, Katy Gallagher, has dismissed concerns about the ACT Health Directorate’s decision to change the way medical internships are allocated at the Canberra Hospital.

Ben Veness