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General medicine Letters 21 February 2022 Free

Introducing general practice enrolment in Australia: the devil is in the detail

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

Rehabilitation Letters 21 February 2022 Free

Potentially preventable hospitalisations of people with intellectual disability in New South Wales

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

General medicine Letters 17 January 2022 Free

Improving knowledge and data about the medical workforce underpins healthy communities and doctors

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

Statistics Letters 13 December 2021 Free

Towards consistent geographic reporting of Australian health research

To the Editor: As systematic reviews in the health literature increase,1 there is an emerging theme of reporting the geographic location of included studies.2,3,4,5,6,7 Approaches to classifying the geographic location of studies have varied. In the cases of Jennings and colleagues5 and Beks and colleagues,6 the authors captured information on study location and then assigned a geographic category. Jennings and colleagues5 followed the classification used by Eades and colleagues8 and combined RA1 and RA2 (originally based on the Australian Statistical Geographical Classification – Remoteness Area)9 to form an urban category. Although these two categories are both urban areas, the Remoteness Areas (RA) imply varying access to services. Beks et al6 opted to report on all five Australian Statistical Geography Standard (ASGS‐RA) categories. Acknowledging the different research questions — the commonality being a better understanding of Aboriginal health activity — Jennings et al5 concluded that urban areas (reported as a combination of RA1‐Major Cities of Australia and RA2‐Inner Regional Australia) were under‐represented, whereas Beks et al6 concluded that RA2‐Inner Regional Australia, RA3‐Outer Regional Australia and RA4‐Remote Australia were under‐represented. When reporting systematic reviews, we recommend that results be presented using all available categories (eg, the five categories of the ASGS‐RA). Authors can then combine categories as required to address their specific research question. Of the reviews identified,2,3,4,5,6,7 the Modified Monash Model (MMM) is yet to be applied.10 With seven categories, the MMM builds upon the five categories of the ASGS‐RA and uses population and road distance to add further granularity. Given the large number of studies that are typically included in a review, it is likely there will be examples across multiple categories. There is direct contemporary policy relevance in adopting the MMM, which spans workforce (eg, Department of Health programs are transitioning to MMM), research translation (eg, 2020 Rapid Applied Research Translation Grant Opportunity), and service delivery (eg, Medicare rebates on telehealth psychology consults).11 A uniform approach to the geographic classification of included studies in systematic reviews would enable greater comparability of findings across reviews. Consistent reporting using the MMM will likely enhance the uptake of health research, and subsequent systematic reviews, by policymakers and funding agencies. This will assist the objective allocation of resources and evaluation of activity of geographically focused programs.

Vincent L Versace · Hannah Beks · James Charles

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Substance‐related disorders Letters 13 December 2021 Free

Screening and brief interventions for harmful alcohol use: where to now?

To the Editor: We read with great interest the article by Holmwood1 which provides a new perspective on alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care settings. Holmwood argues that even though addressing unhealthy alcohol consumption in clinical practice has its place, the effectiveness of SBIRT in reducing alcohol intake is supported by little evidence. The author concludes that emphasis should be placed on strategies with the strongest evidence, such as harm reduction policies. We agree with Holmwood that effective strategies to reduce alcohol consumption should be adopted, and SBIRT itself will not solve the problem entirely. As the author pointed out, the 2018 Cochrane review2 shows that the effect of SBIRT on the reduction of alcohol consumption might be limited. Yet, as stated in the review, we emphasise that while the reduction of alcohol consumption due to brief intervention is relatively small, the benefit on the population level and public health is still likely to be positive.2 With an alcohol intake of 11.9 L per capita (aged 15 years or older), the Czech Republic ranked in the third place in the world in 2019.3 In the Czech Republic, health care professionals are obliged by law to provide SBIRT to their patients.4 However, studies among Czech patients show that less than half of them are asked about their alcohol consumption by their doctor, and only 7.9% of patients are advised to lower their alcohol consumption.5 Studies among Czech doctors report that a quarter do not provide brief intervention to any of their patients.5 It would be interesting to know related information from Australia, but with respect to Czech data, we believe there should be an increased emphasis on the education and training of health care professionals in SBIRT and on supporting general practitioners in providing brief interventions (eg, adequate financial reimbursement of their time) to increase the use of SBIRT in clinical practice. That way, SBIRT can be used to its full potential and complement other strategies to address the high alcohol consumption and related harms.

Jana Malinovská · Jan Brož

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Emergency medicine Letters 13 December 2021 Free

Ambulance ramping, system pressure, and hospitals in crisis: what do the data tell us?

To the Editor: Recent media reports imply there is an increased pressure on Adelaide’s metropolitan emergency medical system which has resulted in additional ambulance ramping and consequent industrial action.1,2,3 We collected a novel dataset of emergency department (ED) capacity state observations at 30‐minute intervals from the public South Australia ED Dashboard4 to investigate the claims of increased pressure. The dashboard uses a traffic light system to indicate ED busyness. The 7‐day moving average of the daily percentage of EDs in “green” status (≤ 80% of capacity) oscillated around 25% between 3 October 2019 and 16 March 2020 and then steeply increased to 80%, coinciding with the first wave of coronavirus disease 2019 (COVID‐19) cases in South Australia, which drove a major reduction in ED presentations (Box).5 The graph then shows a slow return to a baseline fluctuation of around 25% until January 2021. Since then, the moving average of EDs in “green” has been lower than 25%, showing an overall trend of increasing pressure over the subsequent months. This pattern is mirrored in the daily percentage of “red” and “white” status (ED at ≥ 95% of capacity). The 7‐day moving average of the daily percentage of EDs in “red” and “white” status exceeded 75% for the first time in February 2021. Four new record highs have been recorded since 10 May 2021, with the highest daily percentage of “red” and “white” observations at 98% on 27 May 2021. The average daily proportion of “red” and “white” observations pre‐pandemic (from 4 October 2019 to 19 March 2020) was 55% and has since increased to 64% (from 5 December 2020 to 29 June 2021), indicating that EDs are currently under significantly more strain. These issues are not new; EDs are one component of a complex interdependent health care system. EDs operating for extended periods at or near capacity is often the most conspicuous symptom of a broader system under pressure. It is doubtful that a solution to this problem can be found within the ED. Long term ED congestion relief lies in redesigning multiple aspects of the health and social care systems, which should involve health care consumer groups. Suggestions include: i) reducing hospital access block, ii) increasing social and community care, iii) adequate hospital beds, iv) alternatives to traditional care such as urgent care facilities or virtual wards, and v) cohort‐specific interventions to reduce ED presentations (eg, rehabilitation centres for alcohol and substance misuse). Box – Seven‐day moving average of the daily proportions of observations of the six metropolitan public hospitals (excluding the Women’s and Children’s Hospital) classified as alert codes “green” (0–80% occupied capacity), “amber” (80–95% occupied capacity), “red” (95–125% occupied capacity), and “white” (> 125% occupied capacity) between 4 November 2019 and 19 June 2021* * Due to problems in the data collection system, the data for the period between 14 and 31 July 2020 are missing.

Laura M Boyle · Mark Mackay · Keith Stockman

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Substance‐related disorders Guideline summary 29 November 2021 Open Access

Revision of the Australian guidelines to reduce health risks from drinking alcohol

These revised guidelines have three key recommendations which provide evidence-based advice on how to reduce the health risks from alcohol consumption

Katherine M Conigrave · Robert L Ali · Rebecca Armstrong · Tanya N Chikritzhs · Peter d’Abbs · Mark F Harris · Nicole Hewlett · Michael Livingston · Dan I Lubman · Anne McKenzie · Colleen O’Leary · Alison Ritter · Scott Wilson · Melanie Grimmond · Emily Banks

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