Letters

To the Editor: Ibrahim and colleagues1 are to be congratulated for finding a source of information that throws some light on what is happening in Australian aged care facilities, because there is so much positive rhetoric and so little reliable data about aged care coming from the sector itself. The study by Ibrahim and colleagues1 reveals an increase in deaths from external causes, including falls and choking, but we need context. In his 1993–94 report, Gregory2 indicated that in the proposed market-driven aged care system “neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit”. However, the government policy is driving consolidation and corporatisation using a competitive profit-driven model. International data indicate that an increased focus on profitability in aged care is associated with poorer staffing and increased failures in care.3 Studies in Australia and the United States over the past 35 years indicate that, on average, 4 hours or more per person per day of nursing care are required for safe care. Available data indicate that, in Australia, only 2.8 hours are provided. As acuity has increased, the proportion of trained staff has fallen. Our residents receive less than half the nursing time from registered and trained nurses compared with the US and an hour less of total nursing care each day.3 Safe care cannot be provided with these staffing levels; yet, over 95% of facilities are accredited by the Australian Aged Care Quality Agency. Braithwaite and colleagues,4 who have studied the regulation of aged care, conclude that aged care regulation has been captured by the market and is ineffective and warn that “the community should be concerned”. While politicians and the industry talk up our system, it is becoming increasingly clear that the many failures (often in recently accredited facilities) reported in the press are red flags to systemic problems that a succession of captured inquiries into a system that is anything but world class have avoided addressing. With some exceptions, our profession seems to have disengaged from the sector and one wonders if they have been captured too.

J Michael Wynne

To the Editor: The study published by Ibrahim and colleagues1 raises questions about the quality of care delivered in residential aged care facilities. This analysis of routinely recorded coronial data identified that 15% of premature and preventable residents’ deaths resulted from external causes, with falls being the most frequent culprit. Falls in residential aged care facilities are well recognised, with about half of all residents falling within a given year.2 Residents tend to be older and frailer, have higher rates of dementia and higher rates of psychotropic medication use compared with community-dwelling older people, which contributes to higher rates of falls. A falls risk assessment, using validated tools and appropriately qualified personnel, has the potential to reduce the rate of falls and related injuries by addressing individual and environmental risk factors.3 While the residential aged care sector is subject to variation in staffing numbers and skill mix, mandatory education related to falls prevention is also needed. The Australian Commission on Safety and Quality in Health Care’s Preventing falls and harm from falls in older people — best practice guidelines for residential aged care facilities4 provide a helpful framework. In a separate study, Ibrahim, the lead author of the MJA article, and Davis5 state that residents in aged care facilities are entitled to the “dignity of risk” principles that allow them autonomy to accept risks that may be associated with short term increases in their quality of life. However, the reality is that a person’s quality of life is often determined by risk management rather than autonomy,6 which reflects a form of age discrimination whereby the risk of injury of falls and its consequences outweighs the older person’s quality of life, by making assumptions about their ability to make choices about their everyday activities. Promoting dignity and autonomy for older residents in aged care may see greater falls rates but it will allow residents to enact their choices. The work by Ibrahim and colleagues1 needs to be understood within this context.

Judy A Lowthian · Claudia Meyer · Dianne Goeman · Colette Browning

In reply

Joseph E Ibrahim · David L Ranson · Lyndal Bugeja

To the Editor:The recent tragic suicides of young doctors have highlighted concerns regarding the welfare of trainees in our profession. The Trainee Committee of the College of Intensive Care Medicine of Australian and New Zealand (CICM) met in Melbourne in March 2017, and the recent results of the survey1 into bullying and harassment, in addition to the deaths of several junior medical officers to suicide, provided for a solemn meeting. The committee wants to highlight the factors that adversely affect intensive care medicine trainees: bullying, discrimination and sexual harassment;1 staffing and intensity as, while patients’ needs are more complex, staffing has not increased with this intensity of practice; rapid response teams, which are often under-resourced, poorly trained and undersupported; and poor workforce planning and tenuous future job security, compelling junior doctors to pursue increased non-clinical commitments without an allocated time to do so. A consequence of these factors is burnout, which disproportionately affects intensivists and is an increasingly significant risk in trainees.2 Changes in work practices, severity of illness, increased demand for limited resources and increasing intensive care unit size — problems that have recently been addressed by Corke3 — have all played a part in burnout rates. The Trainee Committee welcomes the approach of the CICM to tackle these issues.4 The college is steadfast in its zero tolerance to bullying, discrimination and harassment, and remains committed to fair and equitable access to training. The college also values the need for a reasonable balance between provision of clinical services and time for professional development, and recognises the importance of work–life balance, including part-time training and the provision of parental and other forms of leave. However, the CICM has limited ability to enforce these needs at hospital level. Finally, the CICM embraces rapid response teams, recognising the importance of an appropriately supported service, but hospitals need to respond to this need, and lack of planning and matching training with lifetime workforce demands have to be a priority for the government at all levels. Our specialty will change significantly in the next decade or so. We chose intensive care because we enjoy the work we do and find the challenge it provides rewarding. We must ensure that the next generation of intensivists can meet this challenge too.

Alun T Ellis · Sandra Lussier · Sarah A Yong

To the Editor: I found the article by Kiely and colleagues1 very interesting. The authors concluded that “it should be noted that a relatively small number of imported ZIKV [Zika virus] infections have been reported in Australia, there have been no reported cases of local ZIKV transmission, and the geographical distribution of the potential ZIKV mosquito vector in Australia (Aedes aegypti) is limited to northern Queensland,” and that “at present, ZIKV represents a low risk to blood safety in Australia.”1 Indeed, Kiely and colleagues may be correct in their statement. Nevertheless, without supportive evidence, it seems too soon to draw a conclusion. The estimation of the risk or possibility of transfusion-transmitted ZIKV infection in each setting may be based on mathematical modelling with reference to risk of transmission of other arboviruses in that setting. A good example is the previous report on the estimated risk of transfusion-transmitted ZIKV infection in Thailand.2 However, the lack of reports on ZIKV transmission does not mean that the problem does not exist; many patients with ZIKV infection are asymptomatic and can be easily missed.3

Viroj Wiwanitkit

In reply

Philip Kiely · Erica M Wood · Allen C Cheng

To the Editor: Retinal screening is crucial to the prevention of vision loss from diabetic retinopathy. The recent National Eye Health Survey highlighted a gap in screening rates between Indigenous Australians (aged ≥ 40 years) and non-Indigenous Australians (aged ≥ 50 years),1 providing a foundation on which to target future eye health services. While acknowledging the budgetary and logistical constraints of such a large-scale study, we are concerned that another at-risk group — younger adults with type 2 diabetes who are aged 18–49 years — was not included in the National Eye Health Survey. The past two decades have seen a global increase in the incidence of type 2 diabetes in youth and young adults, with younger age being an independent risk factor for the development of diabetic retinopathy.2 In Australia, about 130 000 people with type 2 diabetes who are aged < 50 years are registered on the National Diabetes Services Scheme.3 However, there are no population-level data available regarding retinal screening rates in this age group. A decade ago, a survey of young Australian adults with type 2 diabetes (aged 16–35 years) reported a 55% retinal screening rate.4 Given the small, self-selected sample, this is likely an overestimate and compares unfavourably with the non-Indigenous rate of 78% reported for adults aged ≥ 50 years in the National Eye Health Survey.1Moreover, our qualitative research has shown that young adults aged 18–39 years who have type 2 diabetes face different psychosocial challenges and barriers to retinal screening compared with their older counterparts aged ≥ 40 years.5 Younger adults with type 2 diabetes require targeted, tailored intervention, which can only be provided if accurate, population-level data are available for this group. As Foreman and colleagues1 acknowledge, diabetic retinopathy is the leading cause of vision loss in working age adults — a situation with potential for considerable social and economic burden. The absence of current eye examination data for younger Australians with type 2 diabetes increases the risk that their needs will be neglected in future evidence-based policy and program delivery initiatives. We urge the Australian Government and other stakeholders to extend future population-level surveys (and other research and policy initiatives) to include all adults with diabetes.

Amelia J Lake · Jessica L Browne · Jane Speight

In reply

Joshua Foreman · Stuart Keel · Mohamed Dirani

To the Editor: We read with interest the recent article by Bonevski and colleagues1 calling for targeting of tobacco cessation interventions to high-risk populations, including prisoners. People who cycle through prisons in Australia smoke tobacco at a rate five times that of the general population,2 and suffer disproportionately from smoking-related morbidity and mortality.3 However, the suggestion by Bonevski and colleagues1 that smoke-free policies in prisons “impact on reducing smoking” is unfortunately a case of misplaced optimism: although these policies reduce smoking in prisons, they have almost no effect on long term smoking behaviour in people who cycle through prisons. Research in the United States shows that about 60% of people released from smoke-free prisons resume smoking on the day of release,4 and 97% relapse within 6 months of release.5 Preliminary findings from a cross-sectional survey we have conducted with 114 ex-smokers released from smoke-free prisons in Queensland paint a similar picture, with 72% of participants reporting relapse on the day of release. Smoke-free policies in Australian prisons are an important public health initiative and should be supported. However, alone they are insufficient to reduce the remarkably high rates of smoking, and of related morbidity and mortality, in the vulnerable populations who cycle through these institutions. There is an urgent need for development and rigorous evaluation of smoking cessation and relapse prevention interventions targeting people released from prison in Australia. Building on the findings of a recent trial in the United States,4 we have recently been awarded funding from the Victorian Health Promotion Foundation to undertake a double-blinded, randomised controlled trial of an intervention designed to reduce relapse to smoking among people released from smoke-free prisons in Victoria. We hope that our study will provide new evidence to guide future efforts to reduce tobacco-related harm in this population. We echo Bonevski and colleagues’1 call for a comprehensive policy shift aimed at reducing tobacco use among disadvantaged populations in Australia. However, prison smoking bans alone are insufficient. Investment in evidence-based efforts to prevent smoking relapse after release from prison will be critical to reduce tobacco-related health disparities in this profoundly vulnerable, marginalised population and realise this important public health opportunity.

Cheneal Puljević · Stuart A Kinner

In reply

Billie Bonevski · David P Thomas · Robyn L Richmond

To the Editor:Emanuel1 enjoins readers to focus on the data concerning euthanasia and physician-assisted suicide (PAS), and to aim at improving the care of dying patients, but advances straw arguments on the basis of three claims in the end-of-life debates that are disputed by neither advocates nor opponents of assisted dying. From the fact that euthanasia and PAS are rarely requested and rarely cause death, Emanuel argues that legalising them will not help solve the problem of inadequate symptom management or improve palliative care. But he adduces no evidence that supporters of legalisation make this claim. Describing legalisation as “really a sideshow in end-of-life care — championed by the few for the few” minimises the plight of those who would avail themselves of euthanasia and PAS, and is belied by the consistent majority support in Western communities for legalisation.2 Pain is recognised, by both advocates and opponents of legalisation, to not be the primary reason why people seek euthanasia and PAS. To claim that the real motivators of requests for assistance (eg, depression, loss of control and loss of dignity) “are not relieved by increasing the dose of morphine, but by antidepressants and therapy”, perpetuates the myth that medicine can, and should, always provide therapeutic answers to such personal dilemmas.3 Emanuel describes requests for euthanasia and PAS as amounting to “traditional suicide condoned and assisted by the medical community”, on the grounds that they are motivated by psychological factors. This statement begs the question about the ethical and legal propriety of euthanasia and PAS by equating PAS with other categories of suicide, without adequate analysis. No one would be surprised at the data supporting Emanuel’s claim that all medical procedures have problems and complications, and that euthanasia and PAS are no exceptions. But to conclude from this that “the common view of euthanasia and PAS as quick, flawless, and painless ways to die is unrealistic” introduces an alleged “common view” that is also unsupported. These are all examples that seem to advance evidence-based arguments in support of a particular ethical and policy position, but one that has been decided ahead of the evidence.

Malcolm H Parker

In reply

Ezekiel Emanuel

To the Editor:I read with interest the call by Menzies and colleagues1 for revitalised efforts to vaccinate a higher proportion of the adult Australian population against common infectious diseases. At present, the aim of the adult component of the National Immunisation Program is to protect against Streptococcus pneumoniae and the two viruses that cause influenza and herpes zoster — all prevalent pathogens in our environment. In addition to infections derived in Australia, adults are more likely than children to be the focus of imported cases of infection. Exposure of adults to, for instance, tropical infectious diseases, including those transmitted by biting insects (ie, dengue, yellow fever, chikungunya and Zika viruses, malaria, etc), will be far greater than that of juveniles. This is because adults have more reason to travel overseas and typically undertake more trips than children do.2 Vaccine uptake among travellers is mixed, and there are groups that are not sufficiently vaccinated, including people who travel overseas to visit friends and relatives (VFR). These so-called VFR travellers are more likely to consider themselves at low personal risk or threat when travelling to their country of origin, stemming from a sense of familiarity with the destination country and its infectious disease risks.3 Cultural beliefs and language barriers are also important factors associated with suboptimal uptake of pre-travel advice among VFR travellers. While infants accompany their parents for holidays and to visit family abroad, intercontinental travel for business and educational opportunities is largely restricted to adults.4 For typical short stay business trips, rather than for holidays lasting an extended period, it is tempting to neglect being up to date with vaccinations.2 In this instance, for the busy business flyer — often a last-minute traveller — the risk aversion to illness may be suppressed by avoidance of the perceived hassle of immunisation. Travel acts as a vector for spread of infection and many outbreaks are imported into Australia through overseas trips; nevertheless, travellers frequently neglect to seek pre-travel health advice.5 Improving rates of travel vaccination, especially in adults, is one area of focus that may help infectious disease control efforts nationally.

Andrew W Taylor-Robinson

In reply

Robert I Menzies · Jenny Royle · C Raina MacIntyre

To the Editor:While vaccine refusal is but one contributor among several to failures of vaccine-preventable disease control, as stated by Beard and colleagues,1 there are important ethical aspects of vaccine refusal. Intentionally opting out of vaccination imposes risks on others, and policies allowing some to opt out weigh their freedom to do so against the rights of others not to be harmed by vaccine-preventable diseases.2 In particular, people who cannot be safely vaccinated (eg, infants) or maintain immunity (eg, the immunosuppressed) are at increased risk of severe disease — including death — and depend on the immunity of others.2 It is true that herd immunity has no “magic threshold”:1 even with high population vaccination levels, severe harm may be caused when just one unvaccinated person has contact with an infectious person and then a vulnerable person. The death of an immunosuppressed woman from measles pneumonitis in the state of Washington, United States, in 2015 is a case in point.3 Tighter legislation on universal vaccination does not unfairly target vaccine refusal. Indeed, Victorian No Jab, No Play legislation has a general objective: “to increase immunisation rates for young children,”4 which applies equally to people who have unintentionally failed to vaccinate and those who intentionally opt out due to hesitancy or refusal. Policy should make vaccination the norm and aim for the highest possible coverage. Moreover, while we should revise financial penalties if they unfairly burden poor families (while the wealthy may pay to opt out), policy should, in some way, recognise that conscientious objection to vaccination has consequences for others.5 Measles outbreaks are correlated with vaccine refusal6 and lead to significant social costs, which Australia may avoid if high levels of vaccination are maintained. Though the true epidemiology is certainly more complex, if measles vaccination leads to immunity in 99% of vaccine recipients, and 95% of people are vaccinated,1 the population level of immunity would be 94.05%. Threshold concepts have limitations, but whether this is “comfortably exceeding” 94%,1 or perilously close to recurrent measles outbreaks — which impose avoidable risks of harm on others — is a matter for debate.

Euzebiusz Jamrozik

In reply

Frank H Beard · Julie Leask · Peter B McIntyre

To the Editor:While highlighting the benefits of endovascular clot retrieval (ECR), Hwang and Gawarikar1 identified Victoria as establishing the first statewide 24/7 ECR service in Australia. We agree with the authors’ caution against focusing on a singular therapy for a few patients at the cost of delivering basic, high quality stroke care to all. As they note in the article, offering ECR requires capacity to appropriately assess patients with advanced imaging and to treat or transfer patients if ECR is indicated.1 We want to provide some background to the ECR service and the role of telemedicine for delivering evidence-based stroke care across regional Victoria, including ECR access. In Victoria, stroke telemedicine has been an important linchpin for overcoming clinical practice variation. The Victorian Stroke Telemedicine (VST) program (www.vst.org.au), operational since 2011, is a statewide service providing 16 regional hospitals with remote access to stroke specialists 24/7.2 The first VST patient eligible for ECR was identified in May 2015, with 78 identified to date. The Victorian Government statewide ECR protocol3 was released in May 2016, with VST being pivotal in identifying and transferring suitable patients from regional areas. Working with regional colleagues through telemedicine has led to numerous benefits,4 including capacity building and incorporating the latest evidence into local stroke protocols. So far, 1600 patients have received a VST consultation, the thrombolysis rate for ischaemic stroke under 4.5 hours is 38% (nationally, 24%),5 some hospitals have provided thrombolysis therapy for the first time, more patients are receiving thrombolysis in under 60 minutes and haemorrhagic complications rates are comparable with those of metropolitan hospitals. Moreover, VST delivers a broader neurological service: 38% of VST consultations receive a “not stroke” diagnosis. We agree that attention to guideline adherence (ie, stroke unit access, care plans and preventive medication) is required.1 Telemedicine may improve access to both basic and specialised care, and in our experience, it provides important infrastructure to incorporate new evidence rapidly. If systems of care could be improved to support rapid uptake of evidence, then geographical boundaries may be overcome: a national acute stroke telemedicine service may be one solution. Commensurate with the need to ensure value, we are undertaking a comprehensive cost effectiveness analysis to support optimal stroke care policy and practice decisions.

Kathleen L Bagot · Dominique A Cadilhac · Chris Bladin

In reply

Yun Tae Hwang · Yash Gawarikar

To the Editor:High technology solutions to the difficult task of selecting and monitoring moles (pigmented skin naevi) may be useful to keep accurate records of people’s skin. Adopting military surveillance and warfare technology,1 there are computer algorithms that search for changes in moles’ appearance over time. Deep convolutional neural networks analysis can group them into benign or malignant lesions with high accuracy.2 In a study by Esteva and colleagues,2 the convolutional neural networks algorithm differentiated between benign, malignant or non-neoplastic lesions with about 72% accuracy compared with about 66% accuracy by two dermatologists; for melanocytic lesions, the algorithm had a better sensitivity and specificity performance compared with the average of 21 dermatologists, although these findings still need to be replicated in independent datasets. Despite recent advances, there are still questions about how Australians can benefit from this technology and how it is best integrated into clinical practice. Cancer agencies worldwide do not recommend screening for melanoma, but instead ask people to make skin self-examinations a habit and present to a doctor with moles of concern — although informal screening is widespread in Australia. Apps that provide easy access to personalised risk estimation may alert people to engage in such exams more frequently. Moreover, apps that guide people through the skin self-examination process may also be useful, as most people find this task complex.3 Once people notice a spot or mole, they may seek a clinical skin examination. Evidence that clinical skin exams are beneficial comes from the Queensland melanoma case control study4 and other similar studies that show that they lead to the detection of thinner melanomas. There are many apps that allow people to take and send photos of moles, but these are highly variable in sophistication and costs. Whether such technology is best placed in front of (for filtering out clearly benign lesions) or after a clinician’s diagnosis (for additional validation) is also matter of debate. Apps should not distract from the patient–doctor relationship, as the final decision about excision requires face-to-face consultations. While technology solutions are promising, validation studies have mostly been small, have lacked a control group or have not been replicated in clinical practice. Independent big research initiatives, such as the International Skin Imaging Collaboration Challenge on Skin Lesion Analysis towards Melanoma Detection,5 are underway to take the momentum further. This healthy competition may be just what is needed to take the last steps to eradicate melanoma.

Monika Janda · H Peter Soyer

To the Editor:I congratulate Isbister and colleagues1 for performing a first aid randomised controlled trial on box jellyfish stings (a rarity in toxinology). The result is at variance with other studies on this topic (although they mainly involved North American jellyfish stings).2 I agree with the authors and the accompanying editorial3 that the major weakness in the study was the up to 4-hour delay for treatment with hot water. Unlike the earlier bluebottle stings first aid study performed on the beach,4 this study is performed in the emergency department of the Royal Darwin Hospital, when the pain severity was lessening. Pain severity was the primary study outcome: 25% of the study group had pain scores of less than 26 (hot water) or 20 (ice), which is minimal pain. Only 10% of the study group received opioid analgesia, compared with the results obtained by Currie and Jacups5 in a 14-year prospective observational study of box jellyfish stings in Darwin, where 48% of patients received analgesia, including 30% of patients receiving narcotic analgesia. The article by Currie and Jacups5 also reported that 71% of patients received ice. The current trial1 does not detail if ice (or heat) was applied to patients before enrolling in the study. Moreover, Currie and Jacups5 also reported that 84% of stings occurred in less than 1 m of water and most of the stings occurred on the legs. I am not sure how the temperature of the water in the bucket used for distal limb stings was controlled to maintain a temperature of 45°C. If not well regulated, then this would lessen the benefits of the heat. In addition, I am surprised that the authors have not attempted to use their findings to push for a standardised approach to jellyfish stings in Australia. The Australian Resuscitation Council currently has different first aid advice for stings in the tropics compared with southern Australia.3,6 These results would suggest that heat is equally effective as ice for box jellyfish stings. The authors were concerned about the difficulty in providing hot water as first aid, which is the same problem for southern Australia, where hot water is recommended. Surely, it is time to standardise first aid for jellyfish stings in Australia.

Mark Little

In reply

Geoffrey K Isbister · Bart J Currie

To the Editor:Cadilhac and colleagues1 explore an important issue in the measurement and reporting of stroke outcomes. We agree that appropriate risk-adjustment methods are essential to compare hospital outcomes. We also agree that stroke severity is an important predictor of mortality for individual patients. However, we do not agree that determining stroke severity is essential for robust risk-adjustment approaches. The Bureau of Health Information has recently published its second report on 30-day mortality.2 Our approach includes adjustment for comorbidity, and we developed separate models for ischaemic and haemorrhagic stroke, given the significant differences in outcomes and risk factors. The approach of Cadilhac and colleagues does neither, which means that we do not know the impact of including comorbidity adjustment and severity in the same model. Further, our method is applicable to small hospitals with as few as 50 patients in a 3-year period. In settings such as Australia, where many patients reside outside major cities, it is important to assess outcomes in both small and large hospitals. The results of Cadhilac et al show that adjusting for stroke severity affected hospital rankings, and across the two models, hospital rates changed on average by 0.01 (range, 0.001–0.026). The impact on outlier status is not described. In our view, it is the outlier status that is the most salient element of public reporting, and indirect standardisation should not be used to rank hospitals.3 Measurement approaches in the United States and Canada do not adjust for severity, and it is not currently possible to do so using administrative records in Australia. While Cadhilac et al have shown that including severity information can affect rankings, such rankings are not appropriate to assess hospital performance when they are based on indirect standardisation and do not take account of hospital size.

Kim Sutherland · Jean-Frederic Levesque · Julia Chessman

In reply

Monique Kilkenny · Leonid Churilov · Dominique A Cadilhac