General medicine

THE COMPLEXITY of neurology is both alluring and intimidating — rather like learning Ancient Greek or a Bach five-part fugue. Attempts at popularisation often fail because of either persistent obscurity or oversimplification. In this book, Professor Roy Beran, from the School of Medicine, Griffith University, Queensland, has produced a practical overview which aims to be approachable without dumbing down.To this task he is eminently suited, ...

Timothy J Kleinig

Ray Moynihan hears a new professional–consumer alliance ringing the alarm on overused interventionsSometimes truth is stranger than fiction. In the United States a few weeks ago, nine leading doctors’ groups published lists of the top five overused tests and treatments within their specialty areas.1 What’s more, they did it with enormous fanfare and in partnership ...

Ray N Moynihan BA

To the Editor: Clinical pathways and guidelines are the inevitable consequence of evidence-based medicine and, in general, have been a force for good in terms of patient care. However, the experiences of Nanan et al1 and Dietz and Stokes,2 and my own experience of working with countless exasperated colleagues in clinical practice, suggest that the ...

Paul M McGurgan

DID YOU KNOW that the McMurray test has been shown to have a specificity of 86% and a sensitivity of 48% for meniscal injury? This text describes a wide range of such clinical signs and also evaluates them for effectiveness, adding invaluable detail not available in other clinical texts.The three authors, two of whom are ...

Sarah J Abrahamson

IT’S 3 O’CLOCK in the morning, and the phone rings. There’s an initial fog of disorientation and, then, I remember ... I grab my smartphone, pen, paper and my trusty handbook and move to a quiet ...

Robert P Dowsett

Opioid use is increasing, and not just for chronic conditions or cancer Global concern about the prescribing of opioid analgesic medications (particularly oxycodone) for chronic pain is growing. In this Journal in September 2011, Roxburgh and colleagues examined the rise of oxycodone and morphine prescribing and the harm associated with opioid use.1 In the accompanying editorial, Hall and Farrell argued that this suggests that most prescribing of opioids was for chronic non-malignant pain.2 We tested this assertion using general practitioner prescribing data linked to the problem under management, and examined the characteristics of the GPs who prescribed opioids and the patients who received these prescriptions. We analysed data from the Bettering the Evaluation and Care of Health (BEACH) program (detailed methods are described elsewhere3). For the period April 2010 to March 2011, we examined encounters at which opioids were either prescribed or supplied directly to patients. We then measured changes in opioid and oxycodone prescribing rates over the past decade and extrapolated these results to all Medicare GP service items claimed nationally.4 While Roxburgh and colleagues1 reported dispensing rates as measured by the Pharmaceutical Benefits Scheme (PBS), BEACH data measure GP prescription and supply actions. Using the international Anatomical Therapeutic Chemical classification,5 we defined opioids as “N02A” and oxycodone as “N02AA05”. We determined the statistical significance of differences by non-overlapping 95% CIs. In the 2010–11 BEACH data year, at least one opioid was prescribed or supplied at 4666 of the 95 839 encounters (4.9%) recorded from 892 GPs (93.1% of the 958 GPs who participated in that year). There were a total of 5350 opioids prescribed (5237; 97.9%) or supplied (113; 2.1%) by the GP at the 4666 encounters. From this point, we shall refer to them all as being prescribed. Compared with encounters at which no opioids were recorded, those at which an opioid was prescribed were four times more likely to be claimable through workers compensation (6.8%; 95% CI, 5.7%–7.8% v 1.7%; 95% CI, 1.5%–1.9%), and more likely to be long or prolonged consultations (10.0%; 95% CI, 8.8%–11.2% v 7.8%, 95% CI, 7.2%–8.4%). Opioids were prescribed at a rate of 3.7 per 100 problems managed, accounting for 5.8% of all medications prescribed or supplied by participating GPs. There was no significant difference in opioid prescribing rates for male and female patients. Opioid prescribing was rare for young patients, rose significantly for patients aged 25–44 years, peaked among 45–64-year-old patients and stayed almost as high in older age groups. Opioid prescribing was significantly less for patients new to the practice, possibly because of their younger age (results not shown) or GP reluctance to prescribe opioids at an initial consultation (Box 1). Commonwealth Health Care Card holders had a significantly higher rate of opioid prescribing than other patients; this rate was even higher than for patients aged 65 years and older, suggesting that age was not the only contributing factor. While the prescribing rate for opioids did not differ with the age group of the GP, male GPs prescribed significantly more opioids per 100 encounters than did females (Box 2), adding to previous research evidence showing that female GPs prescribe fewer medications than males.6 Malignant neoplasms accounted for only 3.5% of opioids prescribed, and chronic non-cancer conditions for a further 43.9%, so a significant proportion were prescribed for conditions classed as non-chronic.7 Almost 60% of prescriptions were for musculoskeletal problems. The higher prescribing rate by male GPs may reflect their higher management rate of musculoskeletal problems when compared with female GPs.6 Back problems accounted for over a quarter of all opioids prescribed and was the most common individual problem for which opioids were provided. About one in 10 opioids prescribed were for osteoarthritis, provided at almost one in five occasions of osteoarthritis management. Less than 7% of opioids prescribed were for generalised multisite pain, but 72.7% of generalised multisite pain managements had an opioid prescribed (Box 2). The most common opioids prescribed were combinations of paracetamol with at least 30 mg codeine (the minimum amount for classification as an opioid). Extrapolation suggests that there were over two million prescriptions for the year, nationally. The next most common opioid was oxycodone, followed by tramadol (Box 2). Over the past decade, the total prescribing rate for total analgesics remained steady4 but the prescribing rate for opioids rose from 3.8 per 100 encounters in 2000–01 to 5.6 per 100 in 2010–11; this was particularly the case for oxycodone (up from 0.3 prescriptions per 100 encounters to 1.5 per 100 over the period). Extrapolation suggests GP prescriptions for opioids almost doubled (from 3.83 million to 6.65 million), while the number of oxycodone prescriptions increased almost sevenfold (from 0.26 million to 1.73 million). These increases reflect both the increased prescribing rate and the increase in the number of GP visits claimed through Medicare in recent years. Our results show that Hall and Farrell were correct in their assertion that chronic non-malignant pain accounted for a far greater proportion of opioid prescriptions than did malignant neoplasms.2 However, we have also shown that a significant proportion of opioid prescriptions are for problems classified as non-chronic. The classification of a problem as non-chronic does not preclude it being chronic in some patients (although it is not usually chronic), nor does it preclude involvement of severe pain over an extended period. 1 Opioid prescribing at Australian general practice encounters by patient characteristics (based on weighted data) Patient characteristics Patients at opioid encounters Patient characteristic opioid prescribing rate per 100 encounters (95% CI) Total encounters 4666 5.6 (5.3–5.9) Sex (missing data, 44) Male 2572 (44.4%) 5.8 (5.4–6.3) Female 2050 (55.6%) 5.4 (5.0–5.7) Age group (missing data, 30) 0–14 years 6 (0.1%) 0.1 (0.0–0.1) 15–24 years 152 (3.3%) 2.0 (1.6–2.3) 25–44 years 1154 (24.9%) 6.1 (5.5–6.6) 45–64 years 1729 (37.3%) 7.7 (7.1–8.3) 65–74 years 734 (15.8%) 6.7 (6.1–7.3) ≥ 75 years 860 (18.6%) 6.5 (5.9–7.0) New patient to practice (missing data, 56) 213 (4.6%) 3.4 (2.8–4.0) Commonwealth concession card (missing data, 304) 2753 (63.1%) 8.2 (7.6–8.7) 2 Opioid prescriptions or supplies (n = 5350) at 4666 Australian general practice encounters (based on weighted data) A: Characteristics of general practitioners prescribing opioids GP characteristics Opioid prescriptions GP age- and sex-specific opioid prescribing rate per 100 encounters (95% CI) Sex (missing data, 0) Male 4150 (77.6%) 6.1 (5.7–6.6) Female 1200 (22.4%) 4.2 (3.8–4.7) Age group (missing data, 17) < 35 years 275 (5.2%) 6.1 (4.6–7.7) 35–44 years 889 (16.7%) 5.1 (4.4–5.7) 45–54 years 1686 (31.6%) 5.4 (4.9–5.9) ≥ 55 years 2482 (46.6%) 5.9 (5.4–6.4) B: Health problems managed with opioids Health problem Opioid prescriptions % of this problem treated with an opioid Back problem* 1449 (27.1%) 37.9% Osteoarthritis† 517 (9.7%) 18.4% Generalised multisite pain 351 (6.6%) 72.7% Fracture† 205 (3.8%) 20.3% Prescription—all† 198 (3.7%) 6.9% Malignant neoplasms—all‡ 187 (3.5%) 10.7% Sprain/strain† 147 (2.7%) 10.5% Migraine 108 (2.0%) 18.1% All musculoskeletal 3114 (58.2%) 17.3% Chronic non-cancer conditions§ 2350 (43.9%) 4.1% C: Main opioids prescribed or supplied Opioids Opioid prescriptions Estimated number nationally in 2010–11 Paracetamol/codeine (30 mg)¶ 1730 (32.3%) 2 130 000 Oxycodone 1406 (26.3%) 1 730 000 Tramadol 864 (16.2%) 1 060 000 Buprenorphine 427 (8.0%) 530 000 Morphine sulphate 371 (6.9%) 460 000 Fentanyl 252 (4.7%) 310 000 Dextropropoxyphene/paracetamol 180 (3.4%) 220 000 * Includes back symptom/complaint, low back symptom/complaint, back syndrome without radiating pain and back syndrome with radiating pain. † Includes multiple International Classification of Primary Care – Version 2 (ICPC-2) or ICPC-2 PLUS codes (see appendix 4 of Britt et al3). ‡ Includes all malignant neoplasms except of skin, for which only melanomas are included. § Chronic conditions are defined as in O’Halloran et al.7 ¶ Paracetamol and codeine combinations with less than 30 mg codeine are not classified as opioids.

Christopher M Harrison BPsych(Hons), MSocHlth · Janice Charles BA, MSc(Med) · Joan Henderson BAppSc(HIM)(Hons), PhD(Med) · Helena Britt BA, PhD

Objective: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices — a perceived barrier that prevents general practitioners from prescribing OST.Design, setting and participants: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August – December 2009.Main outcome measures: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction.Results: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10.Conclusions: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs’ concerns that prescribing OST in their practices would have a negative impact on other patients’ waiting room experiences or on retention of patients seem to be unfounded.

Simon M Holliday FAChAM, FRACGP, FACRRM · Parker J Magin PhD, FRACGP · Janet S Dunbabin PhD · Ben D Ewald MClinEpid, PhD · Julie-Marie Henry RN, DipAppSc(Nursing) · Susan M Goode BSc(Hons), DipMgmt · Fran A Baker BMath · Adrian J Dunlop PhD, GradDipEpi

Objective: To describe values of serum prostate-specific antigen (PSA) in older men without diagnosed prostate cancer, categorised by age and country of birth, and to describe self-reported prostate cancer screening. Design, participants and setting: A cohort study (the Concord Health and Ageing in Men Project) involving a representative sample of 1434 eligible ...

Melisa J Litchfield BAppSc, MPH(Hons) · Robert G Cumming MB BS, MPH, PhD · David P Smith BA, MPH, PhD · Vasi Naganathan MB BS, FRACP, PhD · David G Le Couteur FRACP, PhD · Louise M Waite MB BS, FRACP, PhD · Fiona M Blyth MB BS(Hons), FAFPHM, PhD · David J Handelsman MB BS, FRACP, PhD

Jeremy Bunker, MB BS, FRACGP, was born in Swindon, England, on 10 August 1957 and came to Sydney at the age of 2. Educated at Epping Boys High School, he completed Year 12 in 1975 and, as an accomplished pianist, initially studied at the Sydney Conservatorium of Music. During this time, Jeremy decided he wanted to pursue a medical career and enrolled in medicine at the University of New South Wales. He obtained a first class honours degree in 1983 and was awarded the University Medal, the Wallace Wurth Prize for General Proficiency throughout the Medical Course, the Paediatrics Staff Prize and the Australasian Faculty of Occupational Medicine Prize. Jeremy’s broad interests and genuine liking of people made general practice a natural career choice. After completing his residency at the Prince of Wales Hospital, he set up practice in 1986 in Ultimo with his friend and colleague Dr Kathleen Burns. In 1994, Jeremy attained Fellowship of the Royal Australian College of General Practitioners. First as a general supervisor in 1992 and then as a medical educator in 1996, Jeremy became involved in the Royal Australian College of General Practitioners Training Program, where he helped mentor many registrars in both the science and art of general practice. Over the next 15 years, Jeremy took on many academic and leadership roles in general practice. In 2003, he left the Ultimo practice and was appointed the foundation Director of Training at the Sydney Institute of General Practice Education and Training, which later became GP Synergy. At this time, he also joined the General Practice Unit at Fairfield Hospital as Staff Specialist, where he pursued his interests in chronic disease management and the integration of health service delivery. At a local level, Jeremy served as Chair and as Director of the Central Sydney GP Network. In 2010, he received the RACGP award for Best General Practice Research Article in the Australian Family Physician Journal. Jeremy’s wit, extraordinary facilitation skills, humility, openness and compassion made him a truly exceptional educator. He died in Sydney of lung cancer on 4 May 2011, and is survived by his partner Max, and his children Sophie, Tim and Amelia.

Elizabeth K Marles

To the Editor: The recent article by New and colleagues1 is an important piece in the “bed-block” picture, providing insight into perceived difficulties for patients on discharge, as a result of insufficient appropriate facilities. The authors suggested that “Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers” may improve patient flow through the whole hospital system. This idea fits well with current federal health policy that “bed equivalents” are an important aspect of innovative and flexible models of care for rehabilitation services in Australia.2 Most states are reviewing how rehabilitation services are best designed to ensure the most effective use of limited resources, both in terms of programs and workforce. Improving the coordination of programs managed by the various levels of government, across health, disability and the aged care sectors, will help overcome the barriers identified in this study. The Australasian Faculty of Rehabilitation Medicine applauds efforts to increase research on rehabilitation and patient care, and supports federal and state initiatives providing increased resources for subacute care, both within hospitals and in the community. Investment in rehabilitation services at the community level is one of the most viable solutions and will meet the needs of an ageing population. Effective community care and the proposed National Disability Insurance Scheme (http://www.ndis.gov.au), if well executed, will reduce the burden on other parts of the health and aged care sectors and help ease the burden on hospitals.

Kathleen McCarthy

Non-surgical intervention has many benefits. A recent article published in the Journal1 was widely reported in the popular press, with statements such as the following being quoted: public health messages encouraging people to eat healthy food and to exercise are unlikely to have long-term impact on their weight....

Daniel J Green PhD · Andrew J Maiorana PhD

To the Editor: The decline in the number of National Health and Medical Research Council (NHMRC) scholarships awarded to general practitioners over the past 9 years reflects continuing problems in Australia’s capacity to produce a good base of general practice researchers. Since 1998, 20 GPs have received NHMRC doctoral scholarships; nine of these were granted in 2002 and six were granted after 2002....

Gerard F Gill

Build youth-centric services and they will come.

Elizabeth M Scott BSc(Hons), MB BS, FRANZCP · Daniel F Hermens BSc, GDipSci, PhD · Nicholas Glozier MB BS, FRANZCP, PhD · Sharon L Naismith MCN, DCN, CCN · Adam J Guastella PhD · Ian B Hickie MD, FRANZCP, AM

Anthony Leong was born in Singapore in 1945 and graduated from the University of Malaya in 1969. He pursued postgraduate training in America, where he completed his pathology residency at the University of Washington, Seattle, between 1971 and 1973. In 1976, he migrated to Adelaide to continue his work in lymphoma and tissue processing, especially tissue staining and immunohistochemistry. He excelled in research and, in 1980, received a doctorate in medicine from the University of Adelaide, where he was Clinical Professor of Pathology from 1981 until 1996. From 1996, he dedicated most of his effort and time to the Asia–Pacific region, where he held a number of leading posts including Professor of Anatomical and Cellular Pathology at the Chinese University of Hong Kong and Honorary Professor of Pathology at the Post Graduate Medical Institute, Beijing. From 1999, Anthony was Professor of Anatomical Pathology at the University of Newcastle and Medical Director of the Hunter Area Pathology Service. He was a Fellow of the colleges of pathologists of Australasia, the United Kingdom and America, as well as an honorary Fellow of the Hong Kong and Thai colleges. He served as President of the International Academy of Pathology, Australasian Division in 1995–1996 and was the foundation President of the Asia–Pacific Society for Molecular Immunohistology in 2005–2006. He was also a founding member of the Society of Applied Immunohistochemistry and the International Society for Analytical and Molecular Morphology. Anthony’s most influential footprint was in the field of immunohistochemistry, where he left a great legacy of excellence in research and an unsurpassed love of pathology. He was a prolific author of over 370 original papers, reviews and book chapters, and more than 23 textbooks and monographs. He was a great teacher, a wise mentor and a wonderful leader, who was full of humour and interesting anecdotes. His favourite pastime was golf, and he was a proud member of the “four amigos” golf team at his local club. However, it is fair to say that his golfing never matched the dizzying heights of his academic record! Anthony passed away in late June 2011 after a short battle with cancer. He is survived by his wife Wendy and two children Trishe and Joel, both pathologists.

Huy A Tran · Glen E M Reeves · Frederick W Hetherington

Opportunities to examine the relevance of health interventions in actual clinical scenarios need to be created Evidence-based medicine underpins high-quality health care.1 The use of evidence in the practice of medicine informs appropriate decision making, reduces variability in clinical practice and helps ensure improvement of patient outcomes. Most evidence relating to new knowledge is derived from randomised clinical trials.2,3 However, evidence from clinical trials necessarily involves small and very carefully selected populations with particular demographics and disease characteristics. Hence, the results of clinical trials are often not directly relevant to clinical reality. In addition, the scientific basis of “standard therapy” against which new interventions are compared has not necessarily been rigorously tested. Uncertainty about how best to use such new evidence versus the range of alternative options available in the “real world” may create variable practices and impair patient outcomes. Paradoxically, evidence from these trials is used by the Medical Services Advisory Committee and the Pharmaceutical Benefits Advisory Committee to make decisions about approval and reimbursement of health interventions. Furthermore, while there are obvious ways by which governments and health insurance funds can constrain the costs of new technology, new services and new drugs before their reimbursement, their capacity to influence the use of existing, funded services in a manner that improves the quality of care is limited. In this article, I outline why comparative effectiveness research — examining the applicability of marketed and/or approved products, services and technologies to clinical reality — is critical to the future of health care in Australia. Such research should be funded by the existing health portfolio, as it would not only help reduce clinical uncertainty but, in an era of increasing cost constraints, could improve the efficiency of health expenditure within the framework of existing funded services. Proposal for a new funding streamIt might be assumed that funding from the current National Health and Medical Research Council (NHMRC) competitive grants scheme is sufficient for gathering comparative effectiveness evidence. However, this scheme tends to be focused on innovation, track record and scientific merit, but comparative effectiveness research may not be seen to be as novel as research that seeks to redefine the boundaries of new knowledge. In the United States, a focus on comparative effectiveness research has emerged as a high priority of the current administration.4 Given the limited pool of funds available for medical research in Australia, I propose a new funding program that is ring-fenced for comparative effectiveness research but administered by the NHMRC, with applications assessed on the basis of scientific merit, innovation, improved health and patient outcomes, and cost offsets. The new funding stream should encourage research that: rigorously tests scientifically based variations in approved or standard health interventions that are publicly funded directly compares the relative roles of approved, publicly funded components of treatment algorithms. A separate funding stream dedicated to clinical research that tests standard health interventions would benefit the community and the government — it would provide a means of optimising the utility of previously funded and approved clinical programs. A simple example of the type of project that such funding might realise is the comparison of variations to approved chemotherapy regimens, most of which are derived from historical practice patterns. For instance, the Short Course Oncology Therapy (SCOT) trial — comparing 6 months of chemotherapy (standard care)5 to 3 months of chemotherapy6 for the adjuvant treatment of operable bowel cancer (to determine whether less chemotherapy is not only less toxic and costly but also equally efficacious) — is currently underway in Australia and Europe.7 In addition, research that compares the components of treatment algorithms — conducted within or across disciplines in relevant populations — would enable optimisation of existing health practices, many of which required no specific approval process to have been introduced into standard treatment algorithms. (Modifications to treatment algorithms are often funded by being absorbed into the Medicare Benefits Schedule [MBS] and/or health insurance funds or by state-based programs.) For example, postoperative radiotherapy as adjuvant treatment for locally advanced gastric cancer is considered one standard of care in Australia and the US.8 Implementation of this modality required no formal approval process and the costs of adding radiotherapy to treatment algorithms were subsumed into the costs of standard care. However, because other studies suggest that perioperative chemotherapy (without radiotherapy) may suffice,9 a comparative effectiveness trial would result in considerable insights into the relative utility of the two approaches, with initial trial-related cost-savings providing substantial offset to the cost of the research. Furthermore, such research can do more than determine the role of radiotherapy in the treatment of operable gastric cancer. For example, in the Trial of Preoperative Therapy for Gastric and Esophagogastric Junction Adenocarcinoma (TOPGEAR), the study design process required agreement on evidence-based surgical standards, standardised pathology examination and reporting, and standard chemotherapy regimens for this disease — none of which relate specifically to the experimental intervention.10 Hence, the research process resulted in clinician engagement in a change process that directly affected quality of care. By reducing variability in clinical practice outside the remit of the clinical trial, the research methodology will help ensure high-quality standards for patients, regardless of whether they are enrolled in the study. Similarly, the process of identifying and prioritising a potential question would help facilitate a change process inside and outside the specific research endeavour. The importance of such downstream effects is fundamental to understanding the potential impact of clinical research on the quality of the health system. Other types of more sophisticated research initiatives that test the interface between imaging, surgery and other techniques or practices, as well as the roles of pharmaceuticals, would undoubtedly emerge if the proposed funding stream were created. In so doing, such funding would enhance the capacity of Australian clinicians to promote the health care quality agenda in a cost-effective manner and across various components of the health system, such as the MBS and the Pharmaceutical Benefits Scheme (PBS). It would ensure that comparative effectiveness research initiatives do not have to compete against projects designed to develop new knowledge. A funding stream for comparative effectiveness research would invite research applications which are primarily designed to promote research into existing, funded health practices. Key criteria in funding decisions could include the likelihood of the research resulting in substantial impacts on the quality of patient care, in large numbers of patients, and the potential of the research to engage the broader health care community in a change process. The funding would not only help establish the relative roles of individual PBS- and MBS-funded interventions, but, from a broader viewpoint, would also show the government how clinical research represents a critical component of health care delivery. It would bring a quality focus to funding agencies concerned with the cost-effective delivery of medical services to the Australian community. Getting the new funding stream startedFunds from the existing health portfolio (MBS, PBS, etc) could be directed to a new NHMRC-administered funding stream of $100 million per annum for comparative effectiveness research. To start the program, the National Institute of Clinical Studies could facilitate development of a list of priority areas in three or more areas of health practice (eg, oncology, gastroenterology and rheumatology) by consultation with professional organisations, government agencies and consumer groups — similar to the list of priorities compiled by the US Institute of Medicine.11 This list could be used to pilot the funding program and could subsequently be extended to cover all areas of health practice. While the priorities within each health area could help inform the peer-review process, the call for applications should not discourage unanticipated ideas. In addition, the program should not be designed to provide a dedicated funding source for health economists — rather, it should encourage collaboration between practising clinicians from various disciplines, including experts in fields such as health economics and health system design. ConclusionA funding stream dedicated to comparative effectiveness research would improve health care quality, foster clinical practice research, and increase efficiency and effectiveness in the health system. It would also highlight the value of clinical research.

John R Zalcberg OAM, MB BS, PhD, FRACP

Three features are essential in designing the flexible funding payments and pay-for-performance elements Performance pay for doctors has been introduced in many countries, including the United Kingdom through the Quality and Outcomes Framework (QOF) and the United States through the patient-centred medical home model.1 The effectiveness of these models remains in question, although there is emerging evidence that these schemes can reduce hospital admissions.2-4 In Australia, the Coordinated Care for Diabetes Pilot (CCDP) begins in 2012.5 The key elements of the pilot (Box) are voluntary patient enrolment, a flexible payment for each diabetes patient to cover allied health services (among other things) and a pay-for-performance element. General practitioners will continue to be able to charge fee-for-service payments and claim diabetes-related payments from the Practice Incentives Program (PIP), but will no longer be able to claim the Chronic Disease Management Medicare Benefits Schedule (MBS) items for GP management plans or team care arrangements.5 Doubts about the effectiveness of financial incentives are raised, not only by poor design of evaluations, but also by poor design of funding models. Careful design, based on theory and empirical evidence, is essential in designing interventions to change professional behaviour.6,7 This helps to ensure that the intervention is likely to be effective, and that unintended and undesirable consequences of incentives are minimised. Our aim in this article is to propose three essential features of the flexible payment-per-patient and the pay-for-performance elements of the new CCDP.8,9 Rewarding improvements in quality of careAn objective of the CCDP is that incentive payments will be paid for: . . . the delivery of patient-centred care in accordance with best practice management guidelines for diabetes, and for achieving improvements in patients’ health against specific indicators.5 Payment should be made for improvements in the quality of care, which requires measuring changes in quality over time. Previous schemes have made payments for the achievement of a level of quality, often based on a relatively high threshold, rather than for an improvement in quality. Using thresholds may not lead to changes in behaviour because: (i) doctors in practices with already high levels of quality of care can claim the highest threshold payment without changing their behaviour; (ii) there are no incentives to go beyond the threshold, and (iii) doctors in practices with low levels of quality of care have little incentive to reach a high threshold, as they perceive the costs to be greater than the financial reward.10 One option is to reward improvements in quality between two time points, and set successive thresholds close together, say at 5% intervals.8 This would encourage those with low baseline levels of quality to improve the quality of their care. Furthermore, economic theory would predict that behaviour is only likely to change if the level of the payment is at least equal to the costs of improving the quality of care. These costs will vary across practices depending on their baseline level of quality and the complexity of the health problems of their patients.3 Allowing payments to vary in line with these cost variations would lead to a potentially more effective intervention. The costs of improving quality of care from 10% to 15% are likely to be lower than those of improving from 90% to 95%. Practices that already attain high standards of care find it difficult and costly to improve further and would not be able to claim an improvement payment. Thus, an element of performance pay should recognise the high performance levels already achieved. The “improvement” payment should be higher than the “achievement” payment, or there would be little incentive for practices to improve their quality of care. Avoiding “cream-skimming” and sharing financial riskA fixed payment per patient gives GPs an incentive to minimise costs, as any surplus from the budget can be kept as personal income or reinvested in patient care, and any deficits are borne by the provider.11 This is good for governments, who want to control costs and ensure costs are predictable, because it shifts the financial risk to GPs. However, if this risk is perceived to be too high, GPs may choose not to participate in the scheme or to enrol only “healthy” patients, so a careful balance needs to be struck between risk-sharing and the strength of incentives. The incentives to minimise costs and “cream-skim” are already ameliorated to some extent in the proposed CCDP. GPs can still claim standard MBS items and PIP payments for their patients with diabetes. Total revenue per patient will vary according to the number of visits made per year, and the length of each visit, which partly reflects complexity. However, this may not cover intensity in terms of the use of other resources in the practice, such as practice nurses or the costs of employing allied health professionals. One option is to “risk-adjust” fixed and performance payments, so that higher payments are made to practices with patients with higher needs or more complex health problems than the average. There is much international literature on this subject, including on the use of risk adjustment in the design of the patient-centred medical home pilots in the US.12 Risk adjustment requires data on the primary care costs of diabetes care for all patients and how this varies according to patients’ characteristics. Unfortunately, there are no routinely available data, and very little information on the use of allied health services by patients with diabetes and the associated costs.13,14 Primary care and hospital data would need to be linked to obtain adequate measures of patients’ severity of illness and diabetes complications.14 It is doubtful whether adequate risk adjustment can be developed and implemented in time for the pilot. However, given continued access to MBS and PIP payments, the additional level of risk for practices under the new scheme may not be high, although this will vary across practices. Avoiding exception reportingA further way that cream-skimming can take place for enrolled patients is exception reporting.15,16 Paying for the proportion of patients who achieve a certain target means that payments are based on a ratio, with the numerator equal to the number of patients reaching the target and the denominator equal to the number of patients in the population. Exception reporting occurs when practices exclude patients from the denominator, thus increasing measured performance and earning income, while not improving quality. For example, in the first year of the UK Quality and Outcomes Framework, a median of 5.4% (range, 0–40%) of practices used exception reporting for patients with diabetes. This translated into median gains of between £1700 and £15 000 per practice.15 One way to avoid exception reporting is to make payments based on the numerator only — that is, on the number of patients whose quality of care improves from one period to the next. This would involve a payment for each patient achieving a desired change in performance. Payments can only be increased from one time period to the next if the number of patients achieving a target, or whose quality of care improves, increases. ConclusionThe design of the new payment system in the CCDP should attempt to maximise the impact of the incentives on quality of care while also ensuring an “appropriate” sharing of financial risk with providers, in addition to minimising any unintended consequences, such as exception reporting and cream-skimming. This will partly depend on the validity and reliability of quality indicators, but experience from the Australian Primary Care Collaboratives Program suggests that such data can be extracted from practices. The balance of additional revenue between the flexible payments and performance-pay elements is also crucial, and can influence behaviour as well as costs. Careful design of incentive schemes is essential for their success. Current and new mix of payments for patients with diabetes under the Coordinated Care for Diabetes Pilot (CCDP) Payments Current mix New mix of payments in the CCDP*† 1. Fees for professional attendances For each visit, general practitioners can charge patients what the market will bear, and patients claim (often via their GP) a fixed rebate determined by the MBS. No change‡ 2. Practice Incentives Program Practices can claim payments for patients with diabetes within the PIP (the diabetes sign-on payment, the diabetes service incentive payment for completing a three-visit cycle of care, and the outcomes payment for each diabetes patient if the practice has completed cycles of care for at least 20% of their patients with diabetes). Practices in rural areas (RRMA 3–7) receive a loading on all PIP payments (including diabetes payments) of between 15% and 50%. No change 3. Fees for GP management plans and team care arrangements GPs can claim under MBS items 721 (development of a GPMP), 723 (development of TCA) or 732 (review of a GPMP or TCA). These are fees for each visit (so standard professional attendance fees cannot be claimed), with one GPMP or TCA claim allowed in 12 months (with some exceptions) and one review claim once every 3 months. Patients being managed under the chronic disease management items may be eligible for: allied health services (MBS items 10950–10970); and/or allied health group services (MBS items 81100–81125); and/or dental services (MBS items 85011–87777). There are restrictions on claiming both SIPs and GPMP/TCA/review payments. Practices can no longer claim these fees 4. Flexible funding None A single payment per enrolled patient per year 5. Pay for performance See PIP diabetes outcome payment for completion of cycles of care above. Payments related to improvements in quality of care — to be designed GPMP = GP management plan. MBS = Medicare Benefits Schedule. PIP = Practice Incentives Program. RRMA = Rural, Remote and Metropolitan Areas classification. SIPs = service incentive payments. TCA = team care arrangements. * There are other indirect funding sources for the care of patients with diabetes, including funding for practice nurses, which changed in late 2011 from practice nurse MBS items and payments under the PIP scheme, to fixed subsidies for practice nurse and allied health salaries under the Practice Nurse Incentive Program (http://www.medicareaustralia.gov.au/provider/incentives/pnip.jsp). † The levels of payments are to be determined as part of the implementation of the CCDP. ‡ To the extent that the scheme leads to more visits by patients with diabetes, this will also increase costs to the MBS.

Anthony Scott BA(Hons), MSc, PhD · Mark F Harris MB BS, FRACGP, MD

We need an urgent review of medicines labelling in Australia and New Zealand Almost 25% of patients admitted to hospital a decade ago received inappropriately prescribed medicines.1 As 40% of patients aged over 70 years receive more than five medicines, they are increasingly vulnerable to medication errors.1 Increasing brand substitution due to the proliferation of generic medicines adds to the potential for consumer and practitioner confusion and the likelihood of medication misadventure.2 Clinical scenario: Ms M J, aged 79 years, when questioned about her current prescribed medicines by her physician during an initial consultation, produced a list that included an angiotensin-converting enzyme (ACE) inhibitor, a selective serotonin reuptake inhibitor, a benzodiazepine, an anticonvulsant, and both Oroxine 100 μg and Eutroxsig 100 μg daily; the latter two preparations are both thyroxine sodium. Brand substitu-tion by her pharmacist was confirmed as the cause. There is anecdotal evidence that the progressive increase in innovator (new medicines) and especially generic brand names is associated with inappropriate prescribing and medicine use.3,4 Furthermore, the widespread practice of brand substitution by pharmacists, in which one brand (innovator or generic) is substituted for another, increases confusion, particularly among consumers but also among doctors, nurses and pharmacists. In some cases, such as the above, it can lead to duplicate prescriptions of a medicine.5 Juliet’s reflection in Romeo and Juliet, “What’s in a name? That which we call a rose by any other name would smell as sweet”, may be true for flowers, but clearly not pharmaceuticals. Brand name proliferationAlthough the increasing number of pharmaceuticals has obvious health benefits, the potential for confusion resulting from the thousands of associated brand names requires action. Some prescribers and consumers find brand names more convenient than generic names, but the frequent absence of any relationship between a brand name and the active ingredient or the condition being treated is problematic. Antihypertensive agents illustrate the breadth of brand proliferation. Eight different ACE inhibitors are used in Australia, excluding combinations, whereas 81 brands have Therapeutic Goods Administration (TGA) approval (Box). Enalapril maleate, which has been available for decades, is available in 12 brands, and only six of these use the active ingredient as part of their brand name. While prescribers and dispensers will recognise the active ingredient in these names, many consumers might consider Enalapril-DP and Enalapril Winthrop to be different, and would not necessarily know that Auspril and Alphapril are the same. The proliferation of brands today contrasts sharply with the situation 20 years ago, when only three ACE inhibitor preparations, Capoten, Amprace and Renitec — representing two individual medicines — were available. Even a relatively new generic medicine such as amlodipine is now available in 10 brands, excluding combinations, and many prescribers would be challenged to define the active ingredient of Ozlodip (amlodipine) from its name. Newer brand names of other antihypertensive agents such as Deralin (propranolol), Fibsol (lisinopril), Tryzan (ramipril) and Nyefax (nifedipine) clearly do not contribute to the quality use of medicines. Although there may be marketing sense behind the choice of a catchy name for a new product, generic brands are rarely marketed to prescribers, and pharmacists’ decisions are more likely to be based on cost, not persuasive advertising. Consequently, as a first step, companies that use the active ingredient name within their brand name should be supported. Some companies market the same active ingredient under different brand names but use identical tablet colours and shapes, which may limit brand confusion. However, it is worth noting that Oroxine and Eutroxsig are concomitantly used in the clinical scenario above, and are manufactured by the same company. Consequences of labelling confusionConsumer confusion and adherence problems are related not only to names but also shape, colour, taste, packaging, printing and excipients. The Second national report on patient safety noted that “look-alike or sound-alike” medicine names cause errors and system failures in hospitals and the community.7 The United States Institute for Safe Medication Practices reported that about 25% of serious complications relating to use of medicines resulted from name confusion, with another 25% due to labelling and packaging confusion.8 Another recent US study demonstrated poor emergency department patient knowledge concerning paracetamol in over-the-counter and prescription analgesics: for example, 49% of patients did not know that Tylenol, a commonly used US analgesic, contained paracetamol.9 Lack of knowledge about the paracetamol content of commonly used over-the-counter preparations (including combination products) given to children by parents and carers has resulted in many cases of paracetamol overdose and toxicity in young children.10 Generic brand substitutionAlready a common occurrence in hospitals, generic brand substitution is increasingly practised by community pharmacies. A recent study, which evaluated three major classes of Pharmaceutical Benefits Scheme medicines, found that about 20% of patients switched brands two or more times over 12 months, with the likelihood of substitution directly related to the number of available brands.2 Dealing with brand proliferation and confusionIn 2006, the Australian Pharmaceutical Advisory Council submitted a safe and effective brand substitution policy to government, promoting the use of active ingredient names.11 Unfortunately, this recommendation was not implemented, nor was a subsequent compromise agreement established by the Joint Expert Committee on Labelling Requirements for Medicines. The Pharmacy Guild of Australia has stated that “Medicine naming and packaging is a quality use of medicine issue and requires a systems/continuous quality improvement approach”.12 A recent editorial in the Journal recommended strategies to reduce medication confusion, including clear medicine labels with the active ingredient being displayed with equal or greater prominence to the brand names,13 and this was supported by the Advisory Committee on Prescription Medicines.14 Current TGA labelling guidelines recommend that Both the product name and the active ingredient names and strength should be prominently and equally displayed . . . To distinguish between the product name and the active ingredient name, the first letter of the product name should be in upper case and of the active ingredient name in lower case with a different colour for each. Fonts may be used to differentiate, but all fonts should be clearly legible.15 Guidelines are voluntary and our conclusion is that industry compliance is low. Solutions to the problemWe call on the responsible authorities, as a matter of urgency, to amend Australian and New Zealand drug labelling laws to ensure the active ingredient or generic name is displayed more prominently and in a larger font than the brand name on all pharmaceutical labels, whether prescribed or over-the-counter. This should apply to both innovator and generic products. In addition, to further distinguish between brand and generic names, we propose that the font and colours used for generic names should be unique and comparable for all medicines so as to aid consumer recognition. Brand confusion is a patient safety and a quality use of medicines concern,16 which will only worsen with time if no action is taken. National awareness and incentive campaigns funded by government and industry to ensure that all prescribers and consumers have access to electronic medicines information, including electronic health records, will be a complementary strategy to achieve quality use of medicines for all. Angiotensin-converting enzyme inhibitors available in Australia, 20106 Name No. of brands Captopril 6 Enalapril 12 Fosinopril 6 Lisinopril 17 Perindopril 10 (erbumine 9; arginine 1) Quinapril 9 Ramipril 13 Trandolapril 8 (8 active ingredients — 81 brands)

Shane L Carney MB BS, PhD, FRACP · Madlen Gazarian MB BS(Hons), MSc(ClinEpi), FRACP · Justin T Denholm BMed, MBioethics, FRACP · David M Reith FRACP, PhD · Robert K Penhall MB BS, FRACP, FRCP · Christine R Jenkins MB BS, MD, FRACP · Kay A Wilhelm MD, BS, FRANZCP · Paul A Komesaroff MB BS PhD · Mary M Osborn MPH · Richard O Day MD, FRACP

To the Editor: I read with interest the contrasting perspectives by Pirotta1 and Dwyer2 on the ethics of prescribing complementary and alternative medicine (CAM) interventions, and the subsequent letters on this subject published in the 17 October 2011 issue of the Journal. Individual CAM interventions should be assessed with the same evidence-based approach we would use for any other intervention. Furthermore, any evidence should be interpreted with the same caution as we do for conventional medicines. The efficacy of an intervention should be judged by the quality of the clinical evidence in the context of its scientific plausibility. Whether an intervention should be recommended depends on the context of the other known evidence-based management strategies and the patient’s individual clinical scenario. It is concerning that the supporters of the use of CAM in general practice appear to be willing to make recommendations for treatment in the absence of quality empirical evidence. Both Pirotta and Kotsirilos make the often-used argument that absence of evidence is not evidence of ineffectiveness.1,3 Pirotta suggests that we can turn to tradition1 and Kotsirilos implies that consumer demand indicates effectiveness.3 It should be acknowledged that both tradition and popularity are unreliable forms of evidence. The absence of quality evidence for an intervention should be a major barrier to recommending it, especially when known, effective alternatives exist. This is regardless of the philosophical tradition of the intervention. Even when there is evidence for efficacy, care must be taken in avoiding overreaching conclusions. For example, Kotsirilos interprets the relevant Cochrane review4 as supporting the use of cranberry for prevention of recurrent urinary tract infections in young women.3 That therapeutic recommendation is unjustified. Although the systematic review did find some evidence for cranberry, it noted problems with its quality and the lack of clarity of dosage and administration. The conclusion of the review in 2008 was that “further properly designed studies with relevant outcomes are needed”.4 A well designed randomised controlled trial was published earlier this year; it does not support the use of cranberry for this indication.5

Chun Wah M Tam

Objective: To explore Australian general practitioners’ and pharmacists’ preferences in relation to content, format and usability of drug interaction alerts in prescribing and dispensing software.Design, participants and setting: Surveys that sought opinions on drug interaction decision support were mailed to a random sample of GPs and community pharmacists (1000 of each) in June 2010.Main outcome measures: Usefulness of various components of drug interaction information; preferred format of drug interaction alerts; levels of agreement on the value of various usability features; aspects of drug interaction decision support users would most like to change.Results: Surveys were returned by 219 GPs and 170 pharmacists. Of the 191 GPs and 138 pharmacists included in the analysis, the vast majority considered severity, clinical effects and management advice to be mostly or sometimes useful in drug interaction alerts. The most popular drug interaction alert format — favoured by 131 GPs (69%) and 115 pharmacists (83%) — was one with headings and one or two succinct bullet points under each. The vast majority of respondents also wanted to be able to differentiate drug interaction alerts by severity, and a majority agreed that it should be made more difficult to override alerts for severe interactions and that it should be mandatory to provide a reason for doing so.Conclusions: GPs and pharmacists want drug interaction alert information to be relevant, useful, concise, and easy to read and comprehend. Software vendors and knowledge providers could improve drug interaction decision support by making changes to the content and format of drug interaction alerts according to our recommendations.

Kitty H Yu BPharm(Hons), PhD · Michelle Sweidan BPharm, MPH, MHealthSci (PublicHealthPractice) · Margaret Williamson BPharm, GradDipAppEpi, MPH · Amanda Fraser MB BS(Hons), FRACGP, MPH

This is the first published case series of patients with injuries from watercraft propellers and jet skis. Five patients presented to the level-one trauma centre of Western Australia with such injuries over 10 days during the 2010–2011 Christmas holidays; all required surgery, and all but one sustained multiple, severe injuries. (MJA 2011; 195: 000-000) Clinical recordsPatient 1A 61-year-old man was pushing his boat into the water when he lost his footing and struck the propeller, sustaining a laceration to the lateral aspect of his left ankle. He presented to the emergency department (ED) of a peripheral hospital where his wound was irrigated and sutured. The patient presented to a general practitioner four days later with a painful and erythematous ankle. Erythromycin was commenced and sutures were removed. Four days later, he presented to our ED with worsening pain and spreading erythema and feeling generally unwell. At this time, his wound was intact. He was diagnosed with cellulitis and commenced on doxycycline and cephazolin. The infection abated marginally on the antibiotic therapy, with a decrease in inflammatory markers (the C-reactive protein level and white cell count), but the infection failed to resolve completely. Subsequent intraoperative wound exploration revealed several pockets of debris or soil contamination, and after washout, the wound was closed. The patient subsequently recovered well. Patient 2 A 28-year-old man was riding his jet ski at high speed when he lost control, hit some rocks and was thrown, landing on his right side. He sustained an open fracture of the middle third of the right ulna, fractures of the right distal radius and ulnar styloid, an extra-articular comminuted fracture of the right scapula, right-sided posterior fractures of ribs 9–12 and a dislocation of the right patella with rupture of the anterior and posterior cruciate and medial collateral ligaments. Reduction of the dislocated patella was performed in the ED before the patient was transferred to theatre. Debridement, washout and open reduction with internal fixation of the ulnar shaft and distal radius fractures were performed. The cruciate and medial collateral ligaments were reconstructed 2 weeks later. Antibiotic therapy with cephazolin, metronidazole and ciprofloxacin was provided for 6 days, as advised by an infectious diseases specialist. The patient was discharged from hospital with plans for ongoing physiotherapy and rehabilitation for his knee. Patient 3A 23-year-old man was injured while he and his colleagues were riding jet skis after a Christmas party. A colleague collided with him at high speed, crushing his left leg between their jet skis and causing a subtotal amputation just below the knee; only a small bridge of skin remained. The leg was deemed unsalvageable and the amputation was completed in theatre (Box). Several debridements and washouts were performed before the stump was covered with a latissimus dorsi flap. Antibiotic therapy with intravenous meropenem and ciprofloxacin was given for 22 days on the advice of a clinical microbiologist. The patient will require extensive physiotherapy and occupational therapy during his rehabilitation. He will also need a prosthesis, which will be challenging to develop because of the fastidious nature of the flap and the very short stump (Box). Patient 4A 35-year-old man’s left leg was caught by the propeller of his newly acquired speedboat as he attempted to connect its anchor. He bled profusely and the earliest recorded systolic blood pressure at the scene was 60 mmHg. In the ED, the primary threat to his life was severe hypovolaemic shock from exsanguination, and aggressive fluid resuscitation was instituted, involving multiple units of packed red blood cells. A comminuted fracture of the inferior pole of the left patella and extensive soft tissue injury to the posteromedial aspect of the left thigh were noted before the patient was transferred urgently to theatre. Surgical exploration showed division of the patellar tendon and medial quadriceps tendon as well as transection of the left superficial femoral artery, which was on view. Saphenous vein graft repair was performed, and coverage was achieved with the viable proximal two-thirds of the adductor longus muscle. Intraosseous repairs of the patellar and quadriceps tendons were also performed. After repeated debridement and washout, the large soft tissue defect was covered with a flap. Patient 5A 21-year-old woman was riding in a large rubber tube being towed by a powerboat when she fell out of the tube. When she attempted to climb into the boat, both her legs made contact with the propeller. She sustained limb-threatening soft-tissue damage to both proximal thighs including bilateral sciatic nerve transection, left superficial and profunda femoris artery transections and incomplete left femoral nerve disruption. A displaced open comminuted fracture of the proximal right femur further complicated her injuries. Left superficial femoral artery saphenous vein graft and left leg fasciotomy were performed. Her femur fracture was controlled with an external fixator. Multiple debridements, washouts and vacuum-assisted wound closure dressing changes were undertaken on both legs for wound management. One week later, when the wounds were clean, bilateral sciatic nerve repairs were performed using sural and common peroneal nerve grafts. The patient has been without any lower limb function since arrival at the hospital and the success of her bilateral sciatic nerve repair remains to be seen over the coming months to years. DiscussionThis cluster of incidents occurred over a short period of time in a city whose population has ready access to a range of recreational activities involving watercraft. Western Australia has seen a trend in recent years towards smaller, propeller-driven boats, possibly as a result of the global financial crisis. The number of newly registered large cabin-cruiser boats in WA dropped steadily from 572 in 2006 to 332 in 2010. During the same period, the number of new jet and racing boat purchases remained largely unchanged (17 in 2006 and 18 in 2010, with moderate fluctuations in between these years).1 Furthermore, in the period from December 2006 to March 2011, there were 72 boat and watercraft accidents in WA, seven of which were caused by the propeller (unpublished WA watercraft injury statistics for 2006–2010 held by the Royal Perth Hospital trauma registry). This occurred despite appropriate legislation for licensing, speed restrictions and operating watercraft under the influence of alcohol. Watercraft and propeller injuries are often characterised by severe initial injury and physiological insult, including severe haemorrhage. The cutting nature and high speed of propellers results in repeated wounding of the body at multiple levels, greatly multiplying the risk of irreparable damage to deep neurovascular structures. Also, serious complications can ensue after the initial damage control period, particularly uncontrollable wound infection, often with unusual bacteria which may not be detected by routine culture methods.2,3 This may necessitate amputation, even if a limb may initially appear to have been saved. There has been little progress in the design of safety features for power boats in recent years, with the primary focus on fire management and warning signage around the hull. One maker of jet skis has developed promising features, including a “learner key” which limits speed and a “braking” system. Such innovations may reduce injuries, but the problem of the exposed propeller remains. A concept worth mentioning is that of a propeller guard.4 The guard provides a barrier to the cutting edge of the blades and eliminates the risk of a person making contact with a running propeller. We believe that this is still a relatively unknown idea in Australia, and some retailers suggest that uptake may not be universal among new boat owners. Staff at a major Perth boating retailer believe that people purchasing a boat for speed or associated recreational activities like skiing may be deterred by the potential loss of speed. This case series highlights the issue of injury from boating and small watercraft activities, as well as the need for increased public awareness of these risks. Currently, there is little coverage of this issue in the Australian literature. We believe that the medical community should provide accurate and relevant data, and embrace our role as leaders and health advocates by working with government and other non-governmental organisations to build effective public awareness campaigns and to drive manufacturers and retailers to produce and sell safer products. Injury to Patient 3 and surgical amputation of the leg A. Surgical amputation just below the level of the tibial tubercle (insertion of the patellar ligament). B. X-ray showing postoperative anteroposterior view. C. X-ray showing postoperative lateral view.

Hemant Garg MB BS · Reto Twerenbold MD · Rene Zellweger MB BS, MD, FRACS

Time to find a systems-level model for a serious, undermanaged, but preventable problem For over 20 years, we have known that osteoporotic fractures predispose to further fractures and significant morbidity.1,2 We also understand that first and subsequent fragility fractures are associated with premature death.2-4 However, surprisingly little has happened over the past two decades to translate this knowledge into good clinical practice for our patients. Of course, anyone presenting with a low-trauma fracture to an Australian hospital will get it fixed in due time. But little happens after that. Nobody seems to ask why that person had a low-trauma fracture (or a second or third one) to begin with. Indeed, 75%–80% of patients who have had an osteoporotic fracture are neither being investigated nor treated for their underlying condition — osteoporosis.5,6 This systematic failure is all the more shocking as we have available to us not only one of the world’s best medical systems, but also subsidised pharmacotherapies with proven efficacy to reduce the risk of (re)fracture.7 Recent data from New South Wales reveal that 35% of patients admitted to hospital with an osteoporotic fracture were readmitted with another fragility fracture, often within 1–2 years of the initial event. This accounted for 16 225 essentially unnecessary admissions with a startling average length of stay of 22 days. Of those with refractures, 17% died during the period studied.8 These numbers represent a medical nightmare and a health care systems failure of huge and growing dimensions. Because the Australian population is ageing, the prevalence of osteoporosis has been steadily rising over the past few decades. Currently, 2.2 million Australians live with osteoporosis, and this number is projected to increase to 3 million by 2021.9 While 67 000 osteoporotic fractures were recorded in Australia in 2001, this figure had risen to more than 87 000 in 2007.9 In 2001, the annual total cost of osteoporosis to the Australian health system was estimated at $7.4 billion,10 and it does not require much imagination to anticipate that we will soon spend an even larger amount of our nation’s income on a medical problem that can be treated and, more importantly, effectively prevented. The reasons for such management failures are complex, and include inadequate awareness among doctors and patients of the health hazards related to osteoporosis, and the almost complete lack of effective medical postfracture care.6 While the fundamental need to improve osteoporosis recognition and management has been acknowledged worldwide, attempts to tackle this issue through simple educational campaigns have clearly not translated into improvements in treatment rates.11 In contrast, there is now high-quality evidence that the implementation of system-level models of care reduces refracture rates, morbidity and mortality, hospital bed days and other health system use. The most effective of these interventions are “fracture liaison services” that include targeted case-finding, systematic assessment, appropriate treatment and follow-up, and access to self-management education programs and support systems.12-15 While such programs have been developed by individual clinicians in Australia, most health services seem reluctant to meet the financial and logistical requirements for secondary fracture prevention services. Are we asking for too much? Would public funding for such services be justified? Let us look at the evidence. We recently reported on the clinical effectiveness of a fracture liaison service established in 2005 at Concord Repatriation General Hospital in Sydney.12 This outpatient service is available to all patients with osteoporotic fractures and, over 4 years, reduced the risk of refracture by 80% compared with standard care. Obviously, the service involves human resources and more use of bone densitometry, laboratory testing and medications. The question therefore was whether the benefits provided by the service would be cost-effective. A health-economic analysis published in the latest issue of Osteoporosis International shows that even though the service is comprehensive, it is also highly cost-effective.16 The economic model used for the analysis accounted for all major osteoporotic fractures (ie. hip, forearm, and humerus), their associated direct costs, changes in health utility and, in the case of hip fractures, increases in mortality. Fracture probabilities were calculated from the clinical data, and medical costs for the service and the control arm were derived from reported health resource consumption data. The (very conservative) analysis showed that reducing subsequent fractures through a fracture liaison service led to significant improvements in quality-adjusted life-years (QALYs). Despite higher treatment costs, the total cost of the intervention was only $1300 per patient over a 10-year period, that is, $130 per patient per year. The incremental cost-effectiveness ratio for the service (versus no intervention) was $20 210 per QALY gained, which means that the intervention represents excellent value for money. Indeed, when lower medication costs were introduced (as would be expected over time), the service was cost-saving; that is, the money saved by preventing fractures would be more than the cost of the service.16 The Concord fracture liaison service is one of various possible models, but conceptually can be implemented in any Australian health service. Its proven clinical and cost-effectiveness leave no excuses for not attempting to close the appalling gap in the postfracture care of patients at high risk of fracture.

Markus J Seibel MD, FRACP, PhD

To the Editor: MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) syndrome has not been reported previously in the Aboriginal Australian population. Here, we describe a patient with MELAS syndrome in this population. A 29-year-old Aboriginal Australian woman presented with a 3-day history of seizures and confusion and a background of cognitive impairment, sensorineural deafness, epilepsy and short stature. On admission, she weighed 29.9 kg and was 1.46 m tall (body mass index, 14 kg/m2). She had myopathic facies, generalised mild motor weakness (4/5) and brisk reflexes (3+). These neurological findings represented a stepwise deterioration from previous assessments. On admission, the patient’s blood count, liver function tests, and serum urea, electrolytes and creatinine levels were normal. Her plasma bicarbonate level, anion gap and thyroid function were also normal. The patient had elevated resting arterial lactate (2.7 mmol/L; reference interval [RI], 0.7–2.5 mmol/L) and pyruvate (98 μmol/L; RI, 30–90 μmol/L) levels. The cerebrospinal fluid (CSF) protein concentration was 820 mg/L (RI, 150–500 mg/L) and the CSF lactate level was 5.4 mmol/L (RI, 0.7–2.5 mmol/L). Magnetic resonance imaging of the patient’s brain demonstrated increased T2 signal involving grey and white matter throughout both cerebral hemispheres, most confluent in the right temporal and parietal lobes (Box 1, A). An electroencephalogram displayed a slow rhythm with epileptic activity in the temporal and centroparietal regions. Histological examination of a biopsy of the gastrocnemius muscle was consistent with MELAS syndrome (Box 1, B). Electron microscopy of a muscle biopsy sample revealed mitochondria with abnormally arranged cristae and abnormal electron densities. Mitochondrial respiratory chain enzyme studies on muscle samples were within normal limits, but the common m.3243A>G mutation in the MTTL1 gene was detected in about 70% of the mitochondrial DNA (mtDNA) in muscle tissue and in 10% of the mtDNA of the peripheral blood. MELAS syndrome is a maternally inherited multisystem disorder resulting from mutations in mtDNA.1 Mitochondrial dysfunction leads to the clinical phenotype and lactic acidosis. Cerebral ischaemia unrelated to vascular territories is suggestive of the diagnosis,2 which is confirmed by genetic studies, enzyme assays and histological examination of affected tissue.3 The patient’s family was of Aboriginal Australian descent and she was not aware of any European ancestry. Further inquiry revealed a family history of deafness, diabetes and epilepsy (Box 2). Consequently, the family were offered genetic counselling. A literature review prompted initiation of arginine and coenzyme Q10 therapy.3 Twelve months later, she had good seizure control and had not been re-hospitalised. The disproportionate differences in health between Indigenous and non-Indigenous Australians are often appropriately ascribed to environmental factors. However, potentially treatable causes should always be considered. 1 Magnetic resonance imaging (MRI) and muscle histological studies A. T1-weighted MRI of the brain showing atrophy and enhancing low attenuation lesions. B. Gomori trichrome stain showing a ragged red fibre (black arrow) and two severely atrophic denervated fibres (white arrow). 2 Pedigree of the family of the patient (arrow)

Luke J Conway · Thomas E Robertson · James J McGill · Josh P Hanson

To the Editor: I am responding to the letter from McIntyre and colleagues in which they strongly urged the National Health and Medical Research Council (NHMRC) to increase support for primary health care research.1 Primary health care research is essential to the future of the Australian health system. Unfortunately, few primary care researchers apply to the NHMRC for support. Reflecting our concern about the low application numbers, we held a workshop on primary health care research last year (see http://www.nhmrc.gov.au/media/events/2010). Our statistics show that from 2008 to 2010, just 1% of total applications to the NHMRC for project grant funding designated the field of research as primary health care. The overall success rate for these primary health care grants over the period 2008–2010 (24%) compares favourably with the overall success rate for all project grants (24%) and clinical research project grant success rates (20%) over the same period. It is notable that the annual number of primary health care grant applications peaked early in the decade and have plateaued since 2004 (Box). This possibly reflects the additional funding for primary health care research from other sources, notably the Australian Primary Health Care Research Institute (APHCRI), which has funded a number of research projects since 2001. In 2010, the APHCRI announced funding of more than $3 million in the form of three centres of research excellence,2 four project grants3 and four fellowships.4,5 Number of National Health and Medical Research Council project grant applications with the field of research as primary health care, 2000–2010 Application year No. of applications 2000 7 2001 5 2002 58 2003 42 2004 31 2005 27 2006 28 2007 20 2008 30 2009 30 2010 30

Warwick P Anderson