Environmental health

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 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

To the Editor:Acute stroke management has undergone major transformations with the advent of endovascular thrombectomy, but there remains a large gap in care between metropolitan and rural Australia. While metropolitan stroke centres are currently redesigning their services to expedite intervention for patients eligible for endovascular thrombectomy, rural and remote areas are still lagging behind with basic stroke therapies. Alteplase therapy for acute stroke within 4.5 hours remains the bedrock of treatment. Nevertheless, presenting to a hospital that has the capability to facilitate this treatment is not as simple for a rural patient as for a metropolitan patient. Distance and isolation are major factors in preventing access to treatment, as is lack of local expertise. In addition, there is a paucity of neurologists working in rural Australia. Where Melbourne and Sydney boast one neurologist for every 25 000 persons, rural Australia ranges from one in 100 000–200 000 people (Costello, C. Australian and New Zealand Association of Neurologists Workforce Survey. Sydney: ANZAN; 2016 [unpublished internal report]). There are rural physicians who are skilled in the management of acute stroke, but there remain barriers and reluctance to use thrombolysis within this group.1 The impact of stroke also significantly burdens the rural Indigenous community. In the Northern Territory, the Indigenous population have a three times higher incidence (307 per 100 000 people) of stroke, a younger age of onset (10 years earlier), higher case fatality, higher stroke recurrence and higher cost of lifetime stroke compared with non-Indigenous and metropolitan patients.2,3 Due to remoteness and delays in transfer, Indigenous people often miss the opportunity for acute therapy. Telestroke services are currently being used in certain parts of regional Australia; they are an effective, safe and efficient method of bringing the metropolitan neurologist to the rural patient’s bedside.4 However, more resources must be invested to make this a service that covers all corners of the country. In addition, it is necessary to implement better recruitment strategies for neurologists to rural centres and stroke-specific public health campaigns that are culturally appropriate, and to increase funding for research to design innovative and creative ways to provide comprehensive care to remote patients. Urgent action is required now; otherwise, an isolated part of our country and community will only face greater challenges over time.

Prashanth Ramachandran · James Burrow