Letters

In reply

Leonard Kritharides · Vincent Chow · Tim JR Lambert

To the Editor: We read with interest the recent study by Freed and Allen on the cost to patients of consulting a private specialist physician.1 Although not the main focus of the study, we were intrigued by the disproportionately low bulk-billing rates by physicians in Western Australia. This was highlighted in the local media,2 with an implication that WA physicians are out of step with interstate colleagues on billing practices. We acknowledge there was no such assertion in the article by Freed and Allen.1 The study findings are based on Medicare data supplied by the Commonwealth Department of Human Services.1 However, the data do not appear to differentiate between Medicare billing in private physicians’ rooms (which is the intended target of the study) or elsewhere. Hence, the bulk-billing findings may be confounded by occasions of Medicare billing occurring in outpatient clinics run by public hospitals. Public hospital services are usually funded by state governments. Nevertheless, Commonwealth (ie, Medicare) funded clinics are permitted under an interpretation of the Health Insurance Act 1973 that allows private services to be rendered by specialists within a public hospital.3 Anyone with a Medicare card is eligible to be considered a “private patient”. If bulk-billed, the patient will not suffer any financial disadvantage — or notice any difference — compared with attending an ordinary state government funded clinic. In most cases, revenue from Medicare is not retained by the specialist, but donated to the hospital to defray clinic costs.4 This model permits the creation of new fee-free hospital outpatient services that would otherwise be unsustainable within the existing state funding. In view of the large number of outpatient visits to public hospitals, there could be an inflation of statewide physician bulk-billing rates where Medicare funded hospital clinics are widespread. In our experience, such clinics are rare or non-existent in WA. It would be interesting to reappraise bulk-billing rates if billing episodes occurring at public hospitals could be excluded. We suspect that bulk-billing rates occurring entirely within private specialist rooms are not significantly different between jurisdictions.

Gregory SY Ong · Senq J Lee · Dejan Radeski

To the Editor: The demand for human leukocyte antigen (HLA) typing in the diagnostic work-up of coeliac disease (CD) in Australia has driven a 14-fold rise in testing since 2003 (Medicare Benefits Schedule data, item 71151). Although HLA typing offers limited specificity for CD, its clinical utility results from its exceptional negative predictive value (> 99%) when the specific HLA susceptibility genotypes are not detected.1 Unlike traditional tests for CD, HLA typing results are informative even when the patient is following a gluten free diet. While the accuracy of HLA typing in CD has not been reported, HLA test results are assumed by clinicians to be definitive. Our findings challenge this view. Discrepancies between several patients’ clinical diagnosis of CD and their negative HLA-DQ2 and -DQ8 typing results in AJD’s practice led to repeat HLA testing with another laboratory. The subsequent reporting of a genotype consistent with CD prompted a clinical audit (2013–2016). Of 211 patients with HLA typing results, nine had been coperformed by two separate laboratories (laboratories 1 and 2), either deliberately or inadvertently. Of these nine patients, six returned conflicting results. An additional DNA sample from all six patients was sent for HLA genotyping by a reference laboratory, where genetic susceptibility for CD was confirmed in five patients (Box). Laboratories 1 and 2 differed in the detection of risk alleles and in the interpretation of or reporting of the results in all six cases. Laboratory 2 identified an at-risk allele in only two of the six patients, and of the four patients with a reported negative genotype, two were subsequently confirmed to have definite CD. These preliminary findings raise serious concerns about CD HLA testing errors that adversely affect patient care. Although identified in Queensland, these laboratories routinely outsource their HLA typing to laboratories in New South Wales and Victoria, indicating that several Australian states are involved. We are particularly concerned about laboratories new to HLA testing or laboratories that are not participating in stringent quality assessment programs as the sourced reference laboratory does. Therefore, we suggest that an assessment of the performance and quality control measures of all laboratories offering HLA typing is urgently needed. Consistent adoption of evidence-based guidelines that describe optimal HLA testing and reporting1 should form part of the solution. Box – Human leukocyte antigen (HLA) typing results from three laboratories† Patient Laboratory 1 Laboratory 2 Reference laboratory Confirmed CD “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2/2.5; susceptible to CD Incorrect Confirmed CD “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2; susceptible to CD Incorrect CD excluded “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2; susceptible to CD Incorrect CD not excluded; on GFD “Consistent with DQ8 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” No susceptibility to CD detected Incorrect Normal CD serology “DQ2 and DQ8 not identified; no genotype susceptibility for CD” “DQA1*0505 has been detected; small percentage susceptible to CD” DQA1*05 (HLA-DQ7); low risk susceptibility to CD Incorrect CD excluded “DQ2 and DQ8 not identified; no genotype susceptibility for CD” “DQA1*0505 has been detected; small percentage susceptible to CD” DQA1*05 (HLA-DQ7); low risk susceptibility to CD Incorrect CD = coeliac disease. GFD = gluten free diet. ND = not detected. † The reference laboratory was in the Victorian Transplantation and Immunogenetics Service in Melbourne. In addition to the incorrect typing results, laboratory 2 failed to report the specific alleles detected and laboratory 1 failed to distinguish between HLA-DQ2.5 and DQ2.2.

A James M Daveson · Michael Varney · Kate E Jackson · Jason A Tye-Din

To the Editor:I thank Byard and colleagues1 for their review of risks of herbal products to the Australian community, which highlighted the high rates of use in younger women with a tertiary education and in patients with chronic diseases or comorbidities. Refugee and migrant women represent a group with potentially high rates of use of herbal products as well as other traditional practices, particularly during pregnancy. Ethnobotany surveys found that 90% of women in eastern Ivory Coast and 80% of women in Mali used medicinal plants during pregnancy.2 A prospective cohort study found that 45% of women in China consumed Chinese herbal medicine during pregnancy and the postpartum period.3 The ingestion of soil, clay or chalk has been observed in up to 84% of pregnant women in African countries, and may be complicated by hypokalaemic paralysis, iron and zinc deficiency, lead poisoning, intestinal obstruction and parasitic infestation.4,5 It is commonly reported that migrant women transfer cultural practices to their new country. In the United Kingdom, geophagia is associated with immigrants from South Asia and West Africa.6 Likewise, Congolese and Zimbabwean women commonly consume clay during pregnancy after migrating to Cape Town.7 In addition, the use of skin lightening creams has been reported in 69% of pregnant women on their third-trimester attending a standard maternal centre in Dakar, which may result in maternal Cushing’s syndrome and adrenal insufficiency and in fetal intrauterine growth restriction. Most case reports in the literature describing Cushing’s syndrome due to skin lightening creams have been on African women who had migrated to Australia, the United States or Europe.8 Skin lightening creams may also contain mercury, with the risk of birth defects and irreversible neurological damage to the child. These products are usually obtained over the counter in African shops, and thus are not subject to any form of safety regulation. A further difficulty is that migrant women may not disclose their use of herbal medicines or other traditional products, even when questioned specifically. Therefore, health professionals in Australia should be aware of the risk of use of herbal and other natural products and practices by migrant women, particularly during pregnancy. Engagement with matriarchal figures, nurses and doulas within migrant communities may be valuable in identifying the extent of these practices.

Adam Morton

To the Editor:The recent review by Byard and colleagues1 highlighted the need for tighter regulation and monitoring of traditional herbal products sold in Australia to minimise the risk of exposure to preparations containing toxic substances, including heavy metals. Use of imported Ayurvedic medicines containing high levels of lead is a concerning exposure source among Victorians and elsewhere in Australia.2 Between 2010 and 2015, 1530 incident cases with blood lead levels above 10 μg/dL were notified to the Department of Health and Human Services under the Public Health and Wellbeing Act 2008 (Vic). Eight patients, aged 26–41 years, reported Ayurvedic medicine use, including one case of occult lead poisoning described previously.3 The median blood lead levels were higher in patients using Ayurvedic medicines (median, 79.5 μg/dL [range, 26.1–102.9]) compared with other non-occupational lead exposures (n = 184; median, 16.4 μg/dL [range, 10.0–63.6]). For patients reporting Ayurvedic medicine use, testing was often prompted by clinical symptoms, including abdominal pain and vomiting. All patients obtained different products directly from India (n = 7) or Pakistan (n = 1). Analysis at an independent laboratory revealed that these products had 2000–15 000 times the maximum amount of lead allowed in complementary medicines by the Therapeutic Goods Administration under the Poisons Standard (ie, 10 mg/kg or 0.001%).4 The ease by which these Ayurvedic products were obtained via the internet or by travellers to non-regulated countries means that they remain a difficult product to monitor. It is also concerning that all female patients (n = 3) reported using these products as fertility therapies or for the treatment of morning sickness, as high blood lead levels may be passed onto babies during pregnancy and while breastfeeding.5 We support the assertion that clinical vigilance is necessary in monitoring lead and other heavy metal levels in patients reporting traditional medicine use.2,3 Difficulties may arise if the health-seeking behaviours of people using Ayurvedic therapies result in fewer contacts with health services, reducing opportunities to test individuals at greatest risk. Public health messages about the potential risks of traditional and Ayurvedic medicines were distributed using targeted media for at-risk communities, Chief Health Officer alerts and the Victorian Government’s Better Health Channel.

Tanyth de Gooyer · Rohani Savage · Nicola Stephens

In reply

Roger W Byard · Garth Maker · Michael Bunce

To the Editor: In Adelaide, which comprises 78% of the population of South Australia, municipal wastewater has been subject to bimonthly analysis since 2009 to measure trends in substance use. Beginning in October 2015, there was a precipitous decrease in the detection of oxycodone residues in wastewater samples (Box). This decrease was counter to the long term trend of increasing amounts of this opioid in previous samples. Prescribing data show a continuing increase in the use of prescription opioid analgesics (POAs), including oxycodone, nationally and in SA, during the period between 1992 and 2011.1 There is a strong relationship between the amount of POAs used in a community and the amount of harm from opioid dependence and overdose.1 The cause of this regional trend change in oxycodone use has not been established. On 1 July 2015, there were some significant changes in the regulation of work injuries in SA which led to a decrease in the number of complex long term claimants, and there was also a similar change in South Australian motor vehicle injury regulation in July 2013. Complex injury claims are strongly correlated with POA use;2 however, the role of these factors is highly speculative and there may be many other factors that contributed to the results. The methods used for the bimonthly wastewater analysis in Adelaide have been published before,3 and another group used this process to report changes in population methamphetamine use in Queensland.4 From October 2015, there was a change in the established temporal trend for oxycodone residues detected in Adelaide wastewater (Box). However, over the same period, there is no such trend change for national Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS data for the number of oxycodone prescriptions dispensed (not total doses),5 or for Adelaide wastewater residues of methadone, which is predominantly dispensed for treatment of severe opioid use disorders via a specific program. A limitation of our investigations was that no regional oxycodone prescription or wastewater data from other jurisdictions were available for comparison. Nonetheless, our findings suggest that wastewater analysis could potentially be used to rapidly monitor changes in substance use on a regional basis. Box – Oxycodone and methadone residue in Adelaide wastewater compared with national data for the total number of oxycodone prescriptions supplied, December 2011 – February 20175 PBS = Pharmaceutical Benefits Scheme. RPBS = Repatriation Pharmaceutical Benefits Scheme.

Philip Crowley · Jason M White · Benjamin J Tscharke · Cobus Gerber

To the Editor:We read with interest the excellent review by Scott and colleagues1 on the contribution of sarcopenia to type 2 diabetes in the ageing Australian population. In a prospective Australian cohort of community-dwelling men, we recently found that muscle grip strength and muscle quality, but not muscle mass, were associated with incident type 2 diabetes at 5 years follow-up.2 These associations were not mediated by serum interleukin 6 or tumour necrosis alpha. As we did not examine sarcopenia, nor appendicular lean mass adjusted for body mass index (ALM-BMI), we have undertaken further analysis in 1180 participants with valid sarcopenia data. Their mean age was 56.9 years (standard deviation [SD] ± 10.9), mean ALM-BMI at baseline was 0.950 (SD ± 0.135) and mean peak hand grip strength at baseline was 48.7 kg (SD ± 9.9 kg). At 5 years follow-up, incident type 2 diabetes occurred in 119 participants (10.1%). Baseline ALM-BMI of less than 0.789 occurred in 9.2% of patients (n = 109) and baseline grip strength of less than 26 kg occurred in 1.4% of patients (n = 16), thus only six participants (0.5%) had sarcopenia as defined by the Foundation for the National Institutes of Health Biomarkers Consortium Sarcopenia Project (both ALM-BMI < 0.789 and peak hand grip strength < 26 kg).3 Hence, in our middle-aged Australian cohort of men, the prevalence of sarcopenia was very low. Moreover, while there was an unadjusted association between baseline ALM-BMI of less than 0.789 and incident type 2 diabetes (odds ratio [OR] 2.54; 95% CI, 1.49–4.17; P < 0.001), this attenuated to non-significance after adjustment for age, subcohort, income, fasting plasma glucose, physical activity, family history of diabetes, triglycerides and hypertension (OR 1.73; 95% CI, 0.95–3.05; P = 0.06). However, when analysing ALM-BMI as a continuous variable, the adjusted association was significant (OR per 0.1 unit decrease: 1.33; 95% CI, 1.13–1.58; P < 0.001). Overt sarcopenia may not have a large contribution to type 2 diabetes in community-dwelling Australians. Rather, reduction of skeletal muscle strength, ALM-BMI and muscle quality across the spectrum of healthy values may have greater population level significance. Our previous population-attributable fraction calculations suggest that a substantial proportion of incident type 2 diabetes may be prevented if muscle strength in the Australian community was generally increased.2

Joule J Li · Jonathan W Newbury · Robert J Adams

In reply

David Scott · Barbora de Courten · Peter R Ebeling

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

In reply

Mark Frydenberg · Robert (Frank) A Gardiner

n/a

Rosalie Schultz

In reply

Pamela Palasanthiran · Asha C Bowen

In reply

Luregn J Schlapbach · Justyna A Ostrowski · Graeme MacLaren

n/a

Robyn Hopkins · Kate A Dolan

To the Editor:We commend Milner and colleagues on their most important and timely study, which investigated the age-standardised rates and methods of suicide by health professionals compared with other occupational groups.1 They established that suicide rates for female health professionals, including medical professionals, were higher than for women in other occupations. While suicide rates were higher for male nurses and midwives, those for male medical practitioners were not significantly higher compared with other occupational groups.1 Milner and colleagues considered sex-related stressors in their discussion, in an attempt to understand the gender differences in suicide rates among medical professionals. The authors considered that women working in male-dominated areas face “considerable gender role stress” and may feel pressure to undertake traditional household roles and family responsibilities.1 It is highly conceivable that the abovementioned sex-related stressors may contribute to the sex differential in suicide rates. However, sexual harassment is an important sex-related stressor2 that was not included in their discussion or in Goldney’s accompanying editorial on this topic.3 There is overwhelming evidence to suggest that sexual harassment disproportionately affects women and is an entrenched problem in the medical profession.4,5 Indeed, sexual harassment has been demonstrated to be associated with suicide attempts among female doctors.5 Goldney argues that “ensuring good workplace relationships and equal opportunity, eliminating bullying [and] reducing access to means of suicide” are important pragmatic approaches to overcoming the problem of suicide among health care professionals.3 We propose that redressing sexual inequalities in medicine and eliminating sexual harassment might represent some additional approaches.

Nikki R Adler · Kimberley A Adler

In reply:In their comment on our article,1 Adler and Adler are correct in noting that sexual harassment is a significant issue facing female doctors, as it is for women in many occupations.2 Those who experience sexual harassment are also more likely to experience bullying and other forms of workplace incivility.3 Workplace bullying has also been found to be related to higher risk of suicidality.4 In view of this, we agree that these would be worthwhile targets for prevention initiatives. But the question remains as to whether sexual harassment and the problems regarding gender role stress discussed in our article1 all stem from the same set of causes. A meta-analysis3 noted two systematic sources of sexual harassment: (i) organisational context, including a climate that permits sexual harassment, and policies that do not support the reporting of and action against perpetrators; and (ii) the context of gender in the workplace — for example, the extent to which traditional gender roles are able to be maintained, such as through gender differences in the organisation of work, and the overall proportion of women employed in the job. In our article, we specifically highlighted the maintenance of gender-normative behaviour in medicine as potential stressors for suicide. While we agree that sexual harassment is a significant issue that needs to be addressed, we suggest that this be incorporated into a wider and overall strategy to overcome gender inequality in medicine. This strategy should target the negative personal and organisational (eg, organisation commitment, work withdrawal, job satisfaction) outcomes of harassment,3 and include measures to allow both male and female doctors to care for their families. In addition, to align with best practice in workplace suicide prevention,5 we would also support a stigma reduction campaign, access to treatment for health practitioners who experience poor mental health and suicidal ideation, and support for colleagues and families following bereavement from suicide within the medical profession.

Allison J Milner · Matthew J Spittal · Marie M Bismark

In reply:I thank Adler and Adler for their comment on my editorial on suicide by health care professionals.1 Their proposal of “redressing sexual inequalities in medicine and eliminating sexual harassment” appears to be encompassed in my statement about “ensuring good workplace relationships and equal opportunity [and] eliminating bullying”,1 which they quote in their letter. Regrettably, sexual harassment is common and not unique to medicine, with an estimated prevalence in the workplace of 35–50%.2 Although Adler and Adler refer to the work of Frank and colleagues3 in demonstrating an association between sexual harassment and suicide attempts in female doctors, they do not mention the caveats that the study authors noted. These include that it was “a relationship we cannot determine”; that earlier studies were “based on small numbers and the subject of considerable controversy”; and that “these problems are not unique to women physicians”. Bearing in mind the low base rate discussed in my article, ensuring that equal opportunity, good workplace relations and anti-bullying approaches are standard for health practitioners, and that health practitioners can access general and mental health care, are more realistic and achievable goals that are more likely to return dividends.

Robert Goldney

To the Editor:Advance care planning (ACP) promotes conversations about future health care, in case a person should lose capacity for decision making. Advance care directives (ACDs) provide written documentation of these conversations. Yet, although the Australian Medical Association advocates ACP within routine clinical practice,1 ACD completion rates remain low.2 While recognising numerous barriers to ACP, including patient, practitioner and health care system factors,3 a dedicated ACP Medicare Benefits Schedule (MBS) item number was mentioned in a number of general discussions at the 2016 Advance Care Planning Australia national conference (Melbourne, 15–17 November) as a potential incentive to increase the use of ACDs in primary care. In general, we support this recommendation. Health economics tells us that where there is a shortage of a specific service, as could be argued for ACP, the supply of this service will increase under fee-for-service payment.4 Patients are less knowledgeable about prices, services and associated benefit than providers; however, the existence of an agency relationship5 (where the patient assigns decisional authority on the basis that they have less information) between general practitioners and patients would facilitate ACDs from which patients are most likely to benefit. On the other hand, there is some risk that financial incentives will motivate GPs to do more than is optimal or desired, especially if the service is priced above standard consultation fees. There is also an opportunity cost; if GPs are providing more ACP services they will have less time to provide other primary care services. However, the risk of financial incentives may be mitigated by the non-financial barriers to ACP (fear or reluctance of patients, insufficient GP skills or organisational factors). Therefore, in designing policies to increase uptake, especially where financial incentives are the driver, a multifaceted approach should be considered. Service reimbursement mechanisms and potential barriers should also be balanced against maintenance of ACP values such as patient autonomy and informed decision making. As a starting point, a two-tiered MBS item number could be beneficial, the first item billable for initiation of ACP and the second used for revisitation of ACDs after a given time period (eg, annual review). Subsequent review of policy responses, including patient and medical practitioner input, will be needed to ensure appropriate directions surrounding MBS billing. Further accompanying strategies may be required to address non-financial barriers to ACP uptake.

Amanda Pereira-Salgado · Jennifer J Watts

To the Editor:The well researched narrative review by Bourke and colleagues1 offers a comprehensive overview of immune-related adverse events (irAEs) in cancer immunotherapy and their management. However, care needs to be taken in adopting too broad an approach, particularly in relation to dermatological irAEs. In the article, “rash” is described as an irAE. However, a rash is a clinical sign, not a diagnosis. The cutaneous irAEs reported in association with immune checkpoint inhibitor therapy span a spectrum of dermatoses including (but not limited to) vitiligo, eczema, lichenoid reactions, morbilliform eruptions, prurigo nodularis, bullous pemphigoid, papulopustular eruptions, rosacea, and cutaneous fungal, bacterial and viral infections.2,3 Categorising every cutaneous irAE as a rash precludes patients from obtaining an accurate diagnosis, which in turn encumbers treatment. Topical corticosteroids are a reasonable first-line treatment option for most pathologies (unless the cutaneous irAE is an infection or papulopustular eruption). However, there is a range of corticosteroid molecules, potencies and vehicles, as well as off-formulary preparations available,4 and physicians should be familiar with this class of drugs before prescribing them. Where accurate diagnosis of a cutaneous irAE becomes particularly important is when topical corticosteroids fail. Systemic corticosteroids, while helpful in containing an acute disease process, are seldom the second-line treatment employed by dermatologists. Dermatologists have an arsenal of topical, physical and systemic therapies at their disposal, and the choice of second-line treatment is determined according to diagnosis. We would therefore offer that a multidisciplinary approach is important in the management of the cutaneous toxicities of the new generation of oncological treatments; not only the moderate and severe as suggested, but also the mild and life-threatening. We commend the rapid rate at which our colleagues in medical oncology have become versed in the fundamentals of dermatological care and recognise only too well the limitations in access to dermatology, even in many of the larger teaching hospitals across Australia.5 However, in many respects, this new era of immunotherapy is uncharted territory, and managing the cutaneous toxicities of these medications necessitates an appreciation of the nuances of managing skin disease.

Rose Liu · Pablo Fernandez-Peñas · Deshan F Sebaratnam

To the Editor:With reference to Batterham and colleagues,1 we applaud the call to better align research funding to disease burden. We also address this shortfall in the leading killer: cardiovascular disease (CVD). The federal government deserves praise for establishing the Medical Research Future Fund (MRFF), doubling funding by 2023. This augurs well for the future, but right now, we face an interregnum while the MRFF builds and the National Health and Medical Research Council funding flatlines. Every year, CVD claims the lives of 45 093 Australians,1 accounting for more than one in three deaths. The direct cost of caring for people with CVD in 2008–09 was $7.7 billion per year (or 12% of the total health budget),2 making it the costliest disease group of all. With the current budget at over $120 billion per annum,3 and assuming that CVD continues to cost 10–12% of the health budget, it is likely that the current cost is well over $12 billion per annum.3 The most recent data show that CVD deaths increased for the first time in 4 decades in men aged 55–64 years,3 an increase associated with the rising rates of obesity and diabetes.3 This reflects the unanswered questions related to heart health, which are ripe for exploration. Meanwhile CVD research is funded substantially less than the equivalent disease burden of cancer, receiving about 13.5% — cumulative frequency of about 22% — of the National Health and Medical Research Council total funding between 2008 and 2014.4 A clear consequence is that CVD research suffers from brain drain, as emerging researchers seek sectors where funding is more available. This workforce crisis was highlighted by a recent Australian Cardiovascular Alliance survey, where 65% of CVD researchers say they would leave the sector if funding is not secured. Australian CVD research is of international standing, providing the highest returns of any disease group on research investment, an extraordinary $8 in health benefits for every $1 spent.4,5 The need for a committed workforce skilled in heart research is clear. Funds from the MRFF must be invested in research that reflects the health priorities and disease burden facing the nation, particularly where the market is failing. Such research is an investment not a cost. In 2017, the Heart Foundation will boost research investment by an additional $9.3 million. While substantial for the only major health charity supporting heart research, this is a drop in the ocean to what is needed. Proportionate investment will ensure that the great legacy of cardiovascular research in Australia is retained.

Garry LR Jennings · Jaye Chin-Dusting

To the Editor:In their article, Chen and Jepson1 discussed the advances in coronary artery stent technology. However, the review did not outline the indications for the newer and more expensive technologies mentioned, and did not indicate how stenting compares with the established practice of coronary artery bypass grafting (CABG) for patients with coronary artery disease. How does percutaneous coronary intervention (PCI) compare with CABG based on current evidence? The SYNTAX2 trial is a multinational trial investigating PCI versus CABG. At 5 years, the number of major adverse cardiovascular and cerebrovascular events in the CABG group was 26.9% compared with 37.3% in the PCI group. The 5-year myocardial infarction rate was 3.8% in the CABG group compared with 9.7% for PCI. Moreover, registry data showed that the cardiac death rate was 3.6% for CABG compared with 9.5% for PCI. Therefore, the group concluded that CABG should remain the standard of care for patients with multivessel coronary artery disease.2 A 2014 meta-analysis in JAMA3 comparing PCI with CABG indicated a reduction in mortality (relative risk [RR], 0.73; 95% confidence interval [CI], 0.62–0.86), myocardial infarction (RR, 0.58; 95% CI, 0.48–0.72) and revascularisation (RR, 0.29; 95% CI, 0.21–0.41), with CABG compared with PCI at a follow-up of 4.1 years. The subgroup analysis showed benefits in patients with and without diabetes. The BEST trial4 compares second generation everolimus-eluting stents with CABG. This trial enrolled 880 patients with more than 70% stenosis of two or more coronary arteries, and followed them up to 4.6 years. At 2 years, the primary endpoint of death, myocardial infarction or revascularisation occurred in 11% of patients in the PCI group and in only 7.9% of patients in the CABG group. During long term follow-up, it occurred in 15.3% of patients in the PCI group compared with 10.6% of patients in the CABG group.4 When reviewing the available evidence in the literature, several articles support CABG over PCI.5 The benefits of CABG persist, despite the development of second generation drug-eluting stents. CABG provides superior long term results in patients with multivessel coronary disease in regard to mortality, myocardial infarction and need for revascularisation. Therefore, CABG remains the gold standard of treatment for these patients.

Rohen Skiba · Chris Merry

In reply

Nigel Jepson · Daniel Chen

To the Editor: Since 1 October 2016, under changes in the Medicines Australia code of conduct,1 the names of all doctors receiving payments from pharmaceutical companies are being published online, together with the dollar amount received; the data will remain available for 3 years. Up until now, this information could only be published with the doctor’s consent. This change — part of the latest edition of the code of conduct — is the industry’s response to attempt to legislate for greater transparency. It represents a significant step forward in the transparency of the relationships between doctors and pharmaceutical companies. In 2015, pharmaceutical company-funded educational expenses for doctors included a $70 000 trip to Sweden for six oncologists and a $176 000 trip to Vancouver for nine dermatologists.2 With the new changes, it is likely that doctors will think twice before accepting large pharmaceutical company funding for educational events, given this information will be available to the public. Despite a considerable body of evidence showing that receipt of meals and sponsorship is associated with altered prescribing patterns,3,4 many doctors continue to incorrectly believe that they can effectively manage the influence of pharmaceutical company promotion on their decision making.4 The challenge for the profession is to foster doctor–pharmaceutical company relationships that benefit patients, while maintaining freedom from undue influence on prescribing habits. This requires system and individual change. Medicines Australia should be commended for its efforts to improve transparency; its measures are a lesson for other companies with financial interests relating to the practice and preferences of doctors, including medical devices companies. However, to fully realise the benefit of the code of conduct changes, all information on doctor payments must be accessible via a centralised repository that allows patients and third parties to search for an individual doctor. Regarding individual change, doctors must take heed of the evidence above and eschew gifts and education funding provided by pharmaceutical companies. Moreover, up to date and freely accessible evidence-based information is available via independent organisations such as NPS MedicineWise. Greater transparency in the relationships between doctors and pharmaceutical companies is a positive step to maintaining high levels of accountability and public trust in the medical profession.

Jessica Dean · Malcolm P Forbes · Richard Di Natale

To the Editor:In her MJA article, Murphy poses the question “who are we talking about when we discuss voluntary euthanasia laws?” and presents two hypothetical scenarios.1 The South Australian Voluntary Euthanasia Bill 2016 defines an eligible person as a competent adult, subject to unbearable and hopeless suffering, with no impaired decision-making capacity, and who has lived in the state for no less than 6 months.2 The degree to which the suffering is unbearable is determined subjectively. A person’s suffering is considered hopeless if medical treatment cannot reduce or relieve the suffering to a level that is bearable to the person. The nature, availability and potential effectiveness of such treatment are determined objectively under the provisions of the Bill. As Murphy observes: “Every person’s story is different and we must be careful not to lump them together”.1 It is also true that aged care and mental health systems need much greater government investment. However, this alone will be unable to deal with the highly particularised needs of people whose lives have become unbearable despite the best medical or palliative care. The 2016 Victorian inquiry into end of life choices stated: “Under the existing legal framework, Victorians with serious and incurable conditions and irremediable suffering are exposed to the possibility of a traumatic death. Some are driven to suicide.”3 The inquiry recommended a legal framework to allow assisted dying for the small number of people who seek help to end their suffering. Such legal reform would surely provide great reassurance by ending the fear of enforced protracted suffering, which leads to pre-emptive and often violent suicides. Examples of the tragic circumstances triggering these actions were compellingly recounted by Coroner John Olle before the Victorian inquiry4 and alluded to in Murphy’s own account of reading “emotionally draining” case files of suicides in nursing homes. The legal status quo is an indictment of a civilised society.

Julia M Anaf