Volume 216 Issue 10

Aspirin and other antithrombotics are proven to be effective in reducing ischaemic stroke recurrence

Thanh G Phan · Benjamin Clissold · Henry Ma

Telestroke is an example of technology facilitating the delivery of time-dependent therapies in regional Australia

Carlos Garcia‐Esperon · Christopher F Bladin · Timothy J Kleinig · Helen Brown · Jennifer J Majersik · Andrew Wesseldine · Kenneth Butcher

High prevalence and associated health care and social costs demand a change in health care paradigms for functional neurological disorders

Elizabeth Pepper · Adith Mohan · Kenneth Butcher · Mark Parsons · Jackie Curtis

A combination of targeted vaccinations and COVID-19 public health measures has led to reduced rates of invasive meningococcal disease and influenza

CR Robert George · Robert Booy · Michael D Nissen · Monica M Lahra

Seasonal affective disorder, a well documented syndrome in northern latitudes, has limited credence in Australia

Adriana G Nevarez Flores · Emmanuelle CS Bostock · Amanda L Neil

The Australian and New Zealand living stroke management guidelines provide timely, evidence-based updates to recommendations

Coralie English · Kelvin Hill · Dominique A Cadilhac · Maree L Hackett · Natasha A Lannin · Sandy Middleton · Annemarei Ranta · Nigel P Stocks · Julie Davey · Steven G Faux · Erin Godecke · Bruce CV Campbell

A comprehensive adverse drug reaction registry with validated information would improve patient safety and care

Michaela Lucas · Sandra Vale

The COVID-19 pandemic has revealed that social connection and social factors are critical for the mental health of young people

Fiona Shand · Michelle Torok

Value co-creation supports the delivery of optimal person-centred care in an efficient way

Tina Janamian · Paresh Dawda · Walid Jammal

Understanding drug-related anaphylaxis could improve prescribing practice in Australia

George P Drewett · Jess Encena · Joy Gregory · Lucinda Franklin · Jason A Trubiano

Selective personality-targeted interventions offer an efficacious approach to targeting suicidal ideation in Australian school students

Lucinda R Grummitt · Jennifer Debenham · Erin Kelly · Emma L Barrett · Katrina Champion · Patricia Conrod · Maree Teesson · Nicola Newton

Clinicians and policymakers should develop measures that further mitigate the risk of sport-related repetitive head injury

Catherine M Suter · Andrew J Affleck · Maggie Lee · Alan J Pearce · Linda E Iles · Michael E Buckland

Neglected tropical diseases represent a threat to the health, wellbeing and economic prosperity of billions of people worldwide, often causing serious disease or death

Johanna Kurcheid · Catherine A Gordon · Naomi E Clarke · Kinley Wangdi · Matthew Kelly · Aparna Lal · Polydor N Mutombo · Dongxu Wang · Mary L Mationg · Archie CA Clements · Stephen Muhi · Richard S Bradbury · Beverley‐Ann Biggs · Wendy Page · Gail Williams · Donald P McManus · Darren Gray

To the Editor: Recently published studies have highlighted concerns that pulse oximeter devices may underestimate hypoxia (overestimate oxygen saturation) in patients with dark skin. This occurs at levels where key decisions are made around supplemental oxygen and hospital admission (arterial oxygen saturation [SaO2] 88–94%). Amid the coronavirus disease 2019 (COVID‐19) pandemic, this important public health issue prompted the Therapeutic Goods Administration (TGA) to publish a medical device safety update.1 Long‐standing concerns about reduced pulse oximeter accuracy in people with dark skin2,3 have evolved into characterisation of significant racial discrepancies. A recent article compared 48097 pairs of measurements by pulse oximetry and arterial blood gas (ABG) in adults receiving oxygen across 179 hospitals in the United States. Among patients saturating >92% on pulse oximetry, hypoxaemia (ABG saturation<88%) was nearly three times more common in black patients than in white patients. Graphs illustrate the median oxygen saturation bias for black patients was 3% in the 89–96% range.4 A recent retrospective cohort study analysed registry SaO2 data in 372 individuals (73.1% with COVID‐19) about to undergo extracorporeal membrane oxygenation for respiratory failure. In patients with pulse oximeter readings of 92–96%, ABG oxygen saturation was <88% in 21.5% of black patients and in 10.2% of white patients.5 In these retrospective audits, patient ethnicity was based on hospital record identification, not skin colour. The oximetry devices used were not specified. COVID‐19 guidelines may incorporate pulse oximeter readings into decisions regarding hospital transfer of home‐care patients. Clinicians and services should arguably have lower thresholds for hospital review and admission of patients with dark skin (including Indigenous Australians and those of African and South Asian descent) with borderline oxygen saturations, while balancing risks of increased ABG and invasive treatment rates. Device manufacturers should develop pulse oximeters that perform accurately across more diverse populations. Further research must identify mechanisms of racial discrepancies in oxygen saturation and address them through device design. Calibration and testing processes for existing devices should be strengthened. The pre‐market approval processes of the US Food and Drug Administration currently require that only 15% of a study population have darker skin, while Australia has no specified requirement. The TGA does not regulate pulse oximeters sold directly to consumers (in stores or online) for general wellness or sporting purposes only. There are significant constraints on the scope for regulatory interventions for medical device pulse oximeters: this essential equipment cannot be excluded from the market or its supply compromised; mandating changes to instructions for use may have limited impact; differentiating between devices is hampered by evidence limitations and any consequent actions would be legally fraught; and mandating accuracy studies would be difficult to enforce. Contemporary evidence demonstrates that dark skin is a risk factor for hypoxia being undetected by pulse oximetry. Clinicians should adjust treatments and guidelines accordingly and consider audits of devices used in their institutions. Failure to address this problem at a design and testing level compromises racial equity in health care outcomes.

Jeffrey J Brownscombe · Heather Loane · Bridget Honan

To the Editor: The rapid uptake of telehealth has been a cornerstone of the response to the coronavirus disease 2019 (COVID‐19) pandemic, and has ensured the provision of essential health care despite restrictions and lockdowns. Although not new technology, telehealth has dramatically increased in prominence and received broad acceptance by doctors and patients alike. Given its success, the Australian Government has confirmed the permanent retention of multiple telehealth item numbers within the Medicare Benefits Schedule (MBS).1 However, it is concerning that this announcement also contained the fine print that the long‐standing MBS incentive for providing telepsychiatry consultations to rural and remote patients will be abolished. This is despite patients in rural and remote communities experiencing well established difficulties accessing health care and having poorer outcomes than their metropolitan counterparts.2 Telehealth consultations have occurred in psychiatry since well before the COVID‐19 pandemic, and have filled an important gap in the workforce by increasing services available in rural and remote areas.3 Video‐based consultations are particularly suited to psychiatry as the key skills of history taking, mental state examination, and psychotherapy do not require physical proximity. Delivering diagnostic assessment and psychological treatment via telehealth have long been demonstrated to be effective and tolerable.4,5 The MBS item number 288 was introduced in 2011 as an adjunct billing code that attracted a 50% loading for psychiatric consultations conducted via telehealth for patients located in a rural or remote setting, aged care facility, or Aboriginal health service. This loading incentivised bulk‐billing of these telehealth assessments. The deletion of this item number from 1 January 2022 will likely result in two adverse consequences: i) fewer telepsychiatry consultations to rural and remote locations will be bulk billed, and ii) telepsychiatry appointments that previously were only available for rural and remote patients will increasingly be offered to metropolitan patients. This will ensure fewer and less affordable options. The cessation of the rural loading for telehealth assessments is a retrograde step that is likely to further entrench long‐standing inequities in both access to care and patient outcomes for psychiatric patients who do not live in the cities. The 288 item number should be reinstated or replaced with an alternative funding mechanism to ensure bulk billed consultations continue to be available for rural and remote patients.

Michael J Weightman

To the Editor: The socio‐economic modelling of the impact of a hypothetical disease‐modifying treatment (DMT) for Alzheimer disease by the National Centre for Social and Economic Modelling (NATSEM)1 is an interesting contribution to what is a critical question for policymakers: how effective does a new antidementia treatment need to be to justify a given cost to the community? Unfortunately, the report does not address this, and several internal deficits call into question the conclusions: • The disease progression pathway lacks backwards transitions. It is commonly understood that mild cognitive impairment is an unstable diagnostic state; individuals are at higher risk for transition to dementia, but a predictable proportion also spontaneously revert back to cognitive normality.2 • The durability of DMT efficacy is unrealistic. It is implausible to assume that a 12‐month treatment with an anti‐amyloid will deliver lifelong cognitive benefits after cessation. In the EMERGE and ENGAGE trials,3 the treatment was for the duration of the trials (18 months), and it is generally accepted that this form of treatment will require infusions for years. • The clinical efficacy of DMT is unfounded. Scientific opinion is divided as to whether modification of cerebral amyloid burden has clinical benefits on cognition or daily function. Further, there is no good reason to assume that a 23% relative difference on the continuous measure of cognitive decline observed in EMERGE — incidentally, not replicated in the identically designed ENGAGE trial3 — will translate to a relative difference in categorical transitions between mild cognitive impairment and mild or moderate dementia. Given this is the main driver of projected cost savings, assuming a 25% reduction in such transitions is unrealistic4 and, surprisingly, not subject to sensitivity analysis. • The adverse costs of DMTs are not modelled. It is not appropriate to model presumed clinical benefits of a hypothetical DMT without accounting for the personal, medical and social cost of their documented adverse effects, including cerebral oedema, brain haemorrhage, and falls.2,5 Given that the list price of any such DMT to the health system was also deliberately not modelled, NATSEM is encouraged to address these concerns in a revised report.

Michael Valenzuela

Dr Katie Moynihan trained rurally, has volunteered in remote corners of the world, and now works and teaches in a prestigious environment of excellence

Cate Swannell

Med J Aust 2022; 216 (10 Suppl).