Health services administration

To the Editor: We read with interest the article by Brewster and Waxman1 published in the Medical Journal of Australia. Building kindness and collegiality into regular handover practice is an obligation of increasing urgency in contemporary medical settings. Clinical handover is often led by junior medical staff and can be perceived as a stressful time for them. Junior doctors have expressed fears regarding public approbation as a contributory factor for stress and burnout.2 Obstetric junior doctors within our own tertiary maternity hospital responding to the Australian Medical Association of Western Australia Hospital Health Check survey reported high levels of stress.3 Ultimately, handover is likely to be a precipitating event for stress and anxiety in this group, and addressing psychological wellbeing during this time will have benefits to both staff and patients.4 In 2018, we built kindness into our labour ward handover process, as part of a formal junior doctor wellbeing initiative. The existing handover structure commenced with individual staff introductions for all members of staff in attendance, including name and role for each staff member. We incorporated a specific staff member to handover, whose sole role, stated during introduction, is “I am here to provide emotional support to the team”. This explicit statement places emotional wellbeing of all staff members at the heart of the priorities for the handover session. Induction to the roles and responsibilities of the profession has been identified as part of the purpose of handover.5 By building kindness and support into our organisation on a daily basis, we hope to improve the wellbeing of all staff members involved in this small but vital daily interaction and embed kindness and support in the broader workplace culture. A post‐intervention survey of the response to our emotional wellbeing initiative will be available in July 2019, at which point, we will learn the effectiveness of the added focus on kindness in handover meetings. Preliminary feedback from our junior doctors has been positive.

Alarna Thomas · Katrina L Calvert · Brendan Jansen

In reply

David J Brewster · Bruce P Waxman

To the Editor: We refer to Liaw and colleagues’1 recently published study in the Journal. We acknowledge the positive intentions and rigour of this trial, and empathically concur with Thompson and Thackrah’s2 comment that the results of this research “[do] not mean that efforts to improve cultural competence in health care settings should be abandoned”. To the contrary, this study demonstrates the urgent need for more research to improve cultural competence in the health care setting; in particular, the use of culturally safe research methods that truly benefit Aboriginal and Torres Strait Islander peoples and communities.3 Like Thompson and Thackrah,2 we question the authors’ choice of the cultural quotient questionnaire.4 This generic tool is not designed for assessing cultural competence of health professionals when working with Aboriginal and Torres Strait Islander peoples in Australia. Importantly, it lacks recognition of the unique colonial experiences of Aboriginal and Torres Strait Islander peoples and, therefore, it cannot measure health professionals’ understandings or attitudes about such a key part of any cultural training, where we would hope to see change. We suggest the use of a scale that has been designed and validated by Aboriginal and Torres Strait Islander peoples, such as the Cultural Capability Measurement Tool.5 We fear that, if not carefully interpreted, the study findings have the potential to further complicate and undermine the substantial work — endorsed by the National Aboriginal Community Controlled Health Organisation and the Department of Health — being undertaken to develop the cultural safety of Australia’s health system.6 It is crucial that in all areas of Australia’s health system, including Aboriginal and Torres Strait Islander health, we present a reliable, strategically aligned approach consistent with the vision of an Australian health system free of racism and inequality.6 It is important that we continue to work together to harness the energy and commitment of the workforce towards our shared goals. We look forward to the qualitative findings of the research study.

Sophie Hickey · Roianne West

In reply

Siaw‐Teng Liaw · Vicki Wade

To the Editor: We strongly agree with St Clair and colleagues1 that telehealth is a “game changer” for the provision of health services to Aboriginal and Torres Strait Islander communities in Australia. For more than 15 years, we have been engaging with Indigenous communities throughout Queensland, to plan and establish telehealth services for a range of clinical disciplines, including diabetes, ear, nose and throat, and aged care. Telehealth is contributing to positive changes in our health system and this is evidenced in our recent studies highlighting the value of telehealth for Aboriginal and Torres Strait Islander people. A systematic review of the outcomes of using telehealth for the provision of care to Aboriginal and Torres Strait Islander people reported improved social and emotional wellbeing, clinical outcomes and access to health services.2 Other benefits included improved screening rates and reduced need for travel.3 This review reinforced the importance of partnerships between Aboriginal community controlled health services (ACCHSs) and public hospitals. Telehealth also helps with the delivery of culturally appropriate care. In a qualitative investigative study,4 we found that telehealth allowed specialist care to be delivered from Aboriginal medical services which were familiar to the patient and local care providers. According to this study, a telehealth consultation with a specialist held in the ACCHS resulted in less stress and greater convenience; and also meant that an Indigenous health worker could be present during the telehealth appointment to provide advocacy and support for the patient.4 Telehealth also reduced out‐of‐pocket expense for the patient. These factors contributed to the interpretation of culturally appropriate services. Telehealth is already benefiting Indigenous people throughout Australia. All studies recognise the pivotal role of ACCHSs as advocates for telehealth. While telehealth applications are predominantly reported in rural and remote areas, we believe that telehealth is just as important for the delivery of specialist health care services to metropolitan ACCHSs, in lieu of community members attending mainstream health services. Telehealth is one mechanism to help close the gap. Telehealth empowers community health services and can improve equity of access to health services in rural and remote — and urban — settings.

Anthony C Smith · Nigel R Armfield · Liam J Caffery

To the Editor: Moynihan and colleagues1 make a good case for Australia responding to the complex challenge of reducing the overdiagnosis of clinical disease. However, this challenge should not lead to confusion with the early diagnosis of and the early intervention in preclinical disease, which are the mainstay of secondary prevention. While reducing diagnosis creep and expanding disease definitions are predominantly the realm of the specialist disciplines, primary care is uniquely placed to embrace preclinical disease diagnosis, increasing early detection and intervention, while specialists endorse reducing overdiagnosis, both collaborating in lowering long term costs to the health system. Preclinical disease and its impact are emerging as the logical next challenge. Prediabetes, for example, is almost always present before the onset of diabetes.2,3 Both the American Diabetes Association3 and Diabetes Australia4 have published recommendations on the diagnosis and screening for diabetes and prediabetes. The American Diabetes Association also leads the way in recommending that screening should be considered in children and adolescents who are overweight or obese and who have additional risk factors for diabetes.3 In 2015, the most comprehensive undertaking since Medicare's inception in the 1980s was established to consider how the more than 5700 items on the Medicare Benefits Schedule (MBS) could be aligned with contemporary clinical evidence and practice and improve health outcomes for patients with clinical disease (tertiary prevention).5 Although, the evidence base around early diagnosis and intervention is relatively recent, it is now opportune for the federal government to initiate a second tier to the MBS Review to consider new MBS items, where appropriate, for the early diagnosis of and early intervention in preclinical disease (secondary prevention). Further, this would align well with the new global awareness and endorsement of lifestyle medicine.6 Reversing the underdiagnosis of preclinical disease would be the perfect partner to reversing the overdiagnosis of clinical disease in delivering better health outcomes for patients, while reducing long term costs to the health system.

Eugen Molodysky

To the Editor: I read with interest the article by Moynihan and colleagues1 and commend the authors on their timely review of this important topic. While the article referred to research that had highlighted concerns about overdiagnosis in relation to several medical and surgical conditions, the only psychiatric condition mentioned was attention deficit/hyperactivity disorder. The authors referred to the problem of medicalisation as one of the possible drivers of overdiagnosis in one of the figures within the article, but not in the text of the article — medicalisation is the process by which non‐medical problems become defined and treated as disorders. In 2005, the medical expenditure on identified medicalised conditions in the United States was estimated to be about US$77 billion.2 Medicalisation in psychiatry has been a particular concern because of the problem created by ever‐expanding definitions of mental disorders and lowering of diagnostic thresholds.3 This has been well illustrated by the changes in the diagnostic criteria within the successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, now in its fifth edition (DSM‐5). The effect of a change in the DSM diagnostic criteria was reported in 2001: changes from the third edition (DSM‐III) to the fourth edition (DSM‐IV), with an increase of the variety of stressors (events) considered capable of leading to post‐traumatic stress disorder (PTSD), led to a finding that 38% of DSM‐IV PTSD cases resulted from its wider definition.4 In the DSM‐5 the diagnostic criteria for PTSD have been further relaxed, so that “emotional reactions to the traumatic event” are no longer part of the diagnostic criteria. Another example of overdiagnosis in psychiatry is that of adjustment disorder. A 2008 article stated that there are “huge [numbers] of false‐positives for depressive and anxiety disorders because the context of symptoms is not taken into account,” and that the diagnosis of adjustment disorder “seems, by definition, ideally suited to apply to healthy people in dangerous and uncertain circumstances”.5 It is to be hoped that the 7th international Preventing Overdiagnosis conference in 2019 will include a session on overdiagnosis also in psychiatry.

George Mendelson

In reply

Raymond Moynihan · Alexandra L Barratt · Paul P Glasziou

To the Editor: I commend the Medical Journal of Australia for supporting high quality qualitative research with clear criteria for acceptance for publication1 on the background of increasing concerns these manuscripts are being rejected for reasons not based on the quality of the article submitted.2 However, I am concerned about the article by Chanchlani and colleagues,3 which involves randomised controlled evaluation of a peer mentoring program for new medical interns using qualitative interview‐based methodology.3 The Journal's Editor‐in‐Chief hoped this methodology would “encourage others to use comparable approaches when investigating similar topics”.4 A well conducted randomised controlled trial is considered among the highest level of evidence base for clinical practice; randomisation minimises bias from known and unknown confounders. However, other biases (selection, recall, measurement etc) also need to be controlled for randomised controlled trials to provide valid results and conclusions. Chanchlani and colleagues3 suggested their primary outcome was to assess psychosocial wellbeing and job satisfaction using inductive thematic analysis of data collected in semi‐structured interviews and focus groups at 12 months. This is different from the Australian New Zealand Clinical Trials Registry (ACTRN12618000455268, retrospectively registered) description which is “to determine the perception of the effectiveness of peer support on anxiety and depression;” the psychiatric training of the interviewers and the formal screening or post hoc assessment of the participants’ mental health are unknown. Qualitative research in randomised controlled trials is increasingly common, with new innovative purposes.5 Chanchlani et al3 reported a novel approach to qualitative research incorporating randomised controlled methodology; no quantitative data are apparent in outcome analysis, even though such measurement can be obtained from a post‐program feedback survey for both groups. Interview questions published in the online appendix cannot properly compare satisfaction rate nor assess the state of mental health. More is needed to justify comparative comments such as “participants with mentors reported high satisfaction with the program and a positive impact on stress levels, morale, sense of support, job satisfaction, and psychosocial wellbeing compared with participants without mentors”. It is desirable that the MJA supports innovative qualitative research. Important information may be omitted due to editorial requirements. Nevertheless, vigorous peer review and academic integrity are still needed. Care should be taken when comparative conclusions are made without adequate explanation.

Shyan Lii Goh

In reply

Sonia Chanchlani · Jeremy SL Ong

To the Editor: Patients may require long term anticoagulation for reasons that commonly include deep vein thrombosis, pulmonary embolism or atrial fibrillation.1 In these circumstances, heparin is commonly used for bridging and is discontinued after the effects of warfarin result in a therapeutic international normalisation ratio. It takes approximately 5 days for this to occur because warfarin inhibits the production of vitamin K‐dependent clotting factors II, VII, IX and X.2 The time to therapeutic anticoagulation is a reflection of the half‐lives of the circulating clotting factors and the time for them to diminish from the plasma. This has been our mindset for decades from the perspective of warfarin use. The introduction of direct‐acting oral anticoagulants (DOACs), such as apixaban, dabigatran and rivaroxaban, has resulted in important logistical and clinical benefits in patients admitted to hospital. For example, bridging with heparin is no longer needed3 because DOACs directly inhibit circulating clotting factors resulting in a relatively quick onset of anticoagulation. The maximum concentration in the plasma is achieved within a few hours, which also mirrors its anticoagulant effect.4 Unfortunately, based on internal audits at our institution, our medication safety committee has identified cases in which DOACs were combined with heparin or low molecular weight heparin. During a 38‐day audit period, there were 14 cases involving such duplication. Based on anecdotal discussions, this duplication is partly related to the prescribers’ lack of knowledge with regards to DOACs. Nurses or pharmacists usually intercepted these events such that the overlap occurred for a few doses and no patients were harmed. In the shift from warfarin to DOACs, inadvertent and unnecessary duplicate anticoagulation due to bridging increases the risk of bleeding. Although we seldom use absolutes, we can confidently endorse that there are no circumstances in which DOACs should be combined with another anticoagulant. Prescriber education and clear institutional guidelines may help deal with this issue. In addition, institutions with electronic medical records could optimise clinical decision support systems to prevent such duplication. The combination of DOACs with heparin is a bridge to nowhere.

Mark A Sheppard · Russell Levy · Asad E Patanwala

In reply

Carmelle Peisah · Tiffany Jessop · Henry Brodaty