General medicine

A 73-year-old woman presented to her GP with visual hallucinations

Harry Birrell · Kong‐Chan Tang

To the Editor: Kaur and colleagues propose the ABCD (abbreviated, brief, comprehensive, detailed) approach for older patients.1 Further to that, we propose extending the mnemonic to ABCDEF with E for efficiency and F for feasibility. This would make it more realistic. The Australian population is ageing. Older patients are often beset by numerous comorbidities. Innovative approaches to facilitate minimisation of hospitalisation and early discharge of frail older patients are urgently needed. Comprehensive geriatric assessment is advocated as the gold standard of managing older patients’ medical needs to improve quality of life. It requires specialist geriatrician assessment in geriatric evaluation and management wards. Unfortunately, a minority of older patients end up being admitted to geriatric evaluation and management units, whereas acute medical beds are mostly occupied by older patients where access to comprehensive geriatric assessment is poor.2 Further, the cost‐effectiveness of comprehensive geriatric assessment in specialised units remains unknown and its utility in reducing length of stay and avoiding readmissions is limited.3 The ABCD concept is intriguing. However, it is unlikely to resolve the dilemma of bed occupancy and length of stay of older patients unless the approach is sufficiently efficient and feasible. These elements conveniently extend the mnemonic to ABCDEF. By “efficiency” we mean efficiency in early recognition of their acute issues, establishing a multimodal approach of therapeutic interventions and discharge planning. “Feasibility” of utilising ABCD in various hospital settings must also be considered. Hospital in the home in appropriately selected patients is an example of efficient and feasible comprehensive geriatric assessment based on the ABCD approach.4 For the ABCD to be properly executed, E (efficiency) and F (feasibility) are integral to this approach. Timely access to specialist geriatric care along with improved delivery of primary care for older people are key issues that need to be concurrently addressed.5

Alaa Alghamry · Joseph C Lee

To the Editor: We congratulate Wright and Versteeg1 for their timely article outlining Australian and international experience of patient enrolment in general practice. Missing from the debate, however, is any reflection on the Practice Incentives Program – Indigenous Health Incentive (PIP‐IHI), a voluntary general practice enrolment of Indigenous patients intended to improve chronic illness care. Here, to offer transferrable lessons for informing the rollout of the Voluntary Patient Enrolment scheme (called MyGP),2 we draw on findings from the Sentinel Sites Evaluation — based on administrative data from the Department of Health and more than 700 interviews with Aboriginal health services and general practice3 — and submissions made to the PIP‐IHI review by key stakeholders in 2019.4,5 First, the lack of existing clinical information system capacity to record if a patient was registered with the PIP‐IHI hindered its implementation. Of particular concern were the separate spreadsheets developed to manage patient registration. Short term gains from developing parallel systems did not advance systematic development and use of follow‐up and recall systems in the longer term. Thus, investment in patient registration systems that advance clinical information systems is required. Second, a perception that the PIP‐IHI rewarded paperwork but did not improve clinical outcomes was a disincentive for participation. Administrative requirements were widely considered too burdensome, particularly, annual patient registration that required practices to determine whether patients were previously registered or had duplicate registrations. This resulted in low patient re‐registrations, limiting the potential for the measure to provide longer term community benefit. Hence, to improve participation, the administration burden must be minimised, with flexible, simplified one‐off registration procedures that enable patients to change general practices. Last, given that patients registered for the PIP‐IHI were expected to have a diagnosed chronic disease, it is notable that Tier 1 or Tier 2 payments reflecting continuity of care and planned review were not triggered for about 30% of patients.6 A substantial proportion of PIP‐IHI‐registered patients were either not regularly attending general practices or the practices were not billing for care in a way that triggered payments. Practice staff attributed this to inadequacies in their recall and reminder systems and to difficulties in contacting patients for recall and in getting them to attend a follow‐up appointment. Therefore, incentives need to encourage better care, not just enrolments.

Jodie Bailie · Alison Laycock · Ross S Bailie

In reply

Michael Wright · Roald Versteeg

To the Editor: With great interest we read the article by Weise and colleagues,1 which presents the results of a retrospective cohort study that found higher age‐standardised rates of potentially preventable hospitalisation in people with intellectual disability in New South Wales compared with the general NSW population. Given the great health inequality of people with intellectual disability, we acknowledge the authors’ effort to conduct this valuable study. However, after reading the article, we were left with two questions. First, to be able to interpret the results of this study, a clear description of the population characteristics of both groups is indispensable. Information about parameters such as age and sex of both populations and about the design of the database is of crucial importance. The absence of this information makes it difficult to get a good picture of the population studied and any limitations or biases that need to be taken into account. We recognise that this type of data is not always easy to collect, especially when working with large population databases. Given its importance for interpretation purposes, we see this as a crucial point of attention for future research. Second, in this study, potentially preventable hospitalisations were identified using the definition in the National Healthcare Agreement, progress indicator 18.2 However, in addition to this definition, the circumstances and the exact reason for hospital admission have not been explored, which makes it difficult to conclude whether all hospital admissions could actually have been prevented in clinical practice. Further research would therefore be of great added value to unravel the significance of the study findings by exploring the differences in the rates of potentially preventable hospitalisations to guide possible future reforms of primary and community health care. In conclusion, the article provided us with important knowledge about the rates of potentially preventable hospitalisation of people with intellectual disability. However, the questions mentioned above need to be answered and further research should be conducted to allow a good interpretation of the results.

Karel L Wel · Lydia Kleinjan · Marleen J Leeuw

In reply

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

A 70-year-old man was admitted for investigation of confusion, agitation and falls

Andrew P Gador‐Whyte · Jared Harris · Karen Gunanayagam · Aaron Walton · Andrew Hughes · Eugene Athan

To the Editor: I commend Wijeratne and Earl1 for drawing attention to the retirement issues faced by doctors. Psychological issues are compounded by the lack of legislative provision for doctors to progressively step down from the demands of full registration. Reducing workload is not a simple matter. The impediments to maintaining registration while reducing workload include recency of practice requirements and up to 73 hours per annum of continuing professional development (CPD) for physicians2 — far exceeding that of other health practitioners. Encore careers as described by the authors, while rewarding, could cause issues with the scope of practice requirements. Current guidelines around the definition of “practice of medicine”,3 unless changed, could find doctors practising medicine without a licence. Eighty‐eight per cent of doctors in a local medical association survey (131 respondents; response rate 27%) supported a step‐down approach, with 59% (of 113 respondents) supporting reduced CPD requirements.4 Many doctors see their profession as a calling and retain a strong desire to serve their communities both before and after retirement. Dignity and respect are key to effective transitions to retirement. Doctors often leave the profession on a sour note because their attempts to maintain registration in order to give back to their communities flounder under current regulations. There is despondency around the lack of recognition of their significant expertise and lack of regulator foresight in how to use the vast resource of senior doctors (eg, pandemics, fires, floods, community health needs). Australia appears to lag behind other countries in this regard. In the United States, states such as Pennsylvania offer retiring and retired doctors volunteer licences through their medical boards to volunteer their services for community health programs.5 The Australian Senior Active Doctors Association and the Australian Medical Association Queensland Senior Doctor Craft Group are working to achieve a step‐down approach.6 Other professions recognise and encourage the active participation of retired members; for example, retired lawyers in several states, including Queensland,7,8 can apply for free practising certificates to undertake pro bono work. In many cultures, “senior” is synonymous with wisdom, leadership and excellence. While retirement planning is important, so is addressing practices and regulations that undermine and limit the value that senior doctors can bring to their communities as they transition through the latter stages of their careers.

Geoffrey Hawson

In reply

Chanaka Wijeratne · Joanne Earl

A 76-year-old man with a history of ureteric nephrolithiasis presented with dysuria and sharp, severe right flank pain with radiation to the inguinal region

Roland Z White · Hemant Vanmali · Matthew Sampson

To the Editor: As members of the Australian Rheumatology Association (ARA), we read with great interest the recent article by Russell and colleagues.1 The organisation has long been concerned that current training pathways and health care resourcing are resulting in a discordance between rheumatology health care supply in Australia and community needs. ARA believes the rheumatology workforce is in significant undersupply, ageing and largely focused in cities, and that our current training programs will not deal with these issues. A 2018 ARA survey of members found that 41% of respondents (of which 54.5% work at rural and remote clinics) plan to retire in the next 10 years.2 Our concerns are supported by Western Australian data3 reporting a critical shortfall of rheumatologists that trainee throughput will not address. However, accessing accurate national data has been difficult due to the issues outlined by Russell et al.1 For example, Australian Health Practitioner Regulation Agency (Ahpra) data suggest there are 441 practising rheumatologists in Australia, but the ARA is only able to identify 364 (including non‐members).4 In addition, understanding the community demand for care has been challenging, as this might be assessed through the surrogate of numbers of people on waiting lists, but there is heterogeneity of the referral acceptance guidelines and data collection processes. To this end, ARA has recently partnered with the Public Health Information Development Unit at Torrens University to define the rheumatology workforce in Australia, analyse interaction effects, and understand the relationships across public and private settings. This needs to be linked to disease prevalence data and geographic service area to understand supply and demand. We also need to understand the selection into the training process and pathways in order to drive policy addressing our suspected workforce problems. We strongly believe that any workforce planning research should engage and partner with specialty societies; for example, we believe that ARA is best placed to engage our members to aid understanding of their career choices and practice patterns. We encourage other specialty groups to follow suit and the Royal Australasian College of Physicians to consider their leadership role in this area.

Helen I Keen · Claire Barrett · Catherine Hill