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Rehabilitation Letters 4 February 2019 Free

Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

To the Editor: In reply to Shilling and colleagues,1 the Rehabilitation Medicine Society of Australia and New Zealand refers the authors and readers to our position statement regarding referral for rehabilitation in the home after total knee replacement (TKR).2 Shilling and colleagues1 state that the most important determinant for referral to inpatient rehabilitation was the hospital where the TKR took place. Independent researchers might be more circumspect, considering there is no acknowledgement that Medibank Private did not fund rehabilitation in the home nationally during the study period nor whether their data included outpatient rehabilitation carried out as “same day rehabilitation”, usually coded as inpatient. Also, disturbingly, some of the literature is misrepresented. The unblinded Canadian randomised controlled trial3 comparing a publicly funded combination of rehabilitation in the home and hospital‐based outpatient therapy with inpatient rehabilitation is not generalisable to privately insured Australian patients. Moreover, the Australian randomised controlled trial4 showing equivalent outcomes for the same two groups excluded patients who were appropriately referred for inpatient rehabilitation on the basis of numerous patient factors. The present study included few patient factors and not clinically relevant factors, such as obesity, ability to walk after TKR, or complications.1 Finally, while no patient safety or outcome data were included, the choice to include the dollar value of the previous year's private hospital claims seems gratuitous — are those patients with higher cost to insurers more likely to use inpatient rehabilitation, or perhaps they were just sicker? It is interesting that no reference is made to the 2017 study that found that referrals to inpatient rehabilitation were directly influenced by preferences of the patient, the surgeon, therapists, discharge planners, insurers and others.5

Steven G Faux · Lee Laycock

Rehabilitation Letters 4 February 2019 Free

Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

To the Editor: In their recent article and media release, Schilling and colleagues1 concluded that after total knee replacement (TKR) “some inpatient rehabilitation is low value care”. The research was funded by Medibank Private. The article comes at a time of increasing interest in rehabilitation in the home (RITH) for TKR and other rehabilitation problems. Despite widely proclaimed opinions, there is limited high level evidence regarding outcomes for inpatient rehabilitation versus ambulatory rehabilitation. In research examining the benefits of RITH, higher complexity patients are often excluded from the studies.2 One of the limitations of this article is that important “patient‐related factors … including obesity, pre‐operative physical and mental health … functional performance” and others, “were not available”. A significant gap in the current debate is an almost total absence of nuanced thinking regarding which patients are clinically indicated and safe to have RITH. The authors’ conclusion is only a relatively minor aspect of the real problem, which is to ensure the best outcome for the patient. That is, we must confidently identify the right rehabilitation program, at the right time and in the right place. The Australasian Faculty of Rehabilitation Medicine3 is committed to ensuring high quality rehabilitation medicine services. We believe that: while many patients with uncomplicated TKR may be appropriate for RITH, there are many others for whom RITH is inappropriate or unsafe; the appropriate setting for TKR rehabilitation should be determined on evidence‐based clinical indicators and minimum safety standards;4 all patients with TKR (apart from the most uncomplicated cases) require referral to and assessment by or on behalf of a rehabilitation medicine physician (or other appropriately trained physician); and some ambulatory rehabilitation programs may be appropriate for TKR and other rehabilitation, but they must be evidence‐based, interdisciplinary, led by a rehabilitation medicine physician and adequately resourced, and not simply seen as a cheaper panacea for a struggling system. To achieve the best outcome for patients, decisions must be individualised and patient‐centred and they should start with a referral to a rehabilitation medicine physician, who can determine the right rehabilitation program, at the right time and in the right place. There are circumstances in which RITH is an alternative to inpatient rehabilitation for appropriately selected patients.4 Let's ensure, however, that we do not throw the baby out with the bathwater.

Timothy J Geraghty · Andrew M D Cole · Gregory Bowring

Statistics Research 14 January 2019 Free

Maximising data value and avoiding data waste: a validation study in stroke research

The known: Recent advances in digital infrastructure in Australia allow linkage of administrative and clinical datasets.

Monique F Kilkenny · Joosup Kim · Nadine E Andrew · Vijaya Sundararajan · Amanda G Thrift · Judith M Katzenellenbogen · Felicity Flack · Melina Gattellari · James H Boyd · Phil Anderson · Natasha Lannin · Mark Sipthorp · Ying Chen · Trisha Johnston · Craig S Anderson · Sandy Middleton · Geoffrey A Donnan · Dominique A Cadilhac

Health services administration Letters 10 December 2018 Free

The Australian Health Practitioner Regulation Agency does not require doctors to practise under the name that they are registered under

To the Editor: Within our clinical practice, we sought to establish the qualifications of a medical practitioner. In doing so, we discovered that medical practitioners are not required to practise under the name that they are listed under on the Australian Health Practitioner Regulation Agency (AHPRA) Register of Practitioners. A practitioner may register under one name, then practise under another. We see this as problematic for patients and inconsistent with the function of the register. AHPRA states that the register “has accurate, up to date information about the registration status of all registered health practitioners in Australia. It is an important way the National Registration and Accreditation Scheme helps keep the public safe”.1 The national register lists all practitioners registered with AHPRA and any conditions on their registration. Patients may access this information if they feel unable to make enquiries directly of a practitioner, or if they wish to view particulars before seeing the practitioner. AHPRA states that “if a practitioner's name does not appear on the register, they are not registered to practise in Australia”. The stated exemption to this statement is that “in a very small number of cases, the details of a registered health practitioner may not appear on the register because of personal safety issues”.1 It is under Part 10 of the Health Practitioner Regulation National Law Act 2009 that each national Board is empowered to maintain the register of all health practitioners currently registered by that Board.2 We note the current consultation paper by the COAG Health Council,3 in preparation for a second tranche of amendments to the National Law, which includes the proposal that the National Law be amended to “enable a practitioner to nominate one or more aliases or additional names to be recorded on the public register, with the register searchable using the alias”.3 We believe this relatively simple measure is consistent with the rights of the practitioner to use a favoured name and of the patient to confirm a practitioner's registration. We therefore support this change.

Katinka Morton · Grant Lester

Letter to the Editor2
Health services administration Letters 10 December 2018 Free

The Australian Health Practitioner Regulation Agency does not require doctors to practise under the name that they are registered under

In reply: The national online register of practitioners is a vital part of Australia's system of regulating health practitioners to assure patient safety. It makes accessible to the public and employers the names of all health practitioners who are registered to practise. It also provides important information about limits or restrictions placed on the way a registered practitioner is allowed to practise. The national online register must remain an authoritative source of trusted information on health practitioners, so consumers can rely on it for accurate and up to date information to inform their health care decision making. Through our work, we have become aware that some health practitioners practise their profession using an alias rather than their legally recognised name published on the register. The Australian Health Practitioner Regulation Agency (AHPRA) has asked governments to consider an amendment to the Health Practitioner Regulation National Law Act 2009 to enable a practitioner to nominate one or more aliases to be recorded on the public register. We are pleased that this proposal is now the subject of public consultation. AHPRA believes that recording additional names or aliases on the register would help inform and protect the public, by making it easier to identify a practitioner who may not be practising under their legal name. There are some operational and practical issues to consider. A clear definition of an alias is required so health practitioners can readily understand their obligations to inform AHPRA and the national Boards of the use of these names. Consideration would need to be given to the requirements for practitioners to provide up to date information on the use of aliases in their practice, and whether any verification of this is necessary. The validity of the register could be compromised by information that is unverified or out of date. Finally, there may be risks from unintended consequences, including whether publishing aliases could be used for commercial gain or benefits not related to public information and protection, which is the focus of the National Law. AHPRA awaits the outcomes of the current public consultation process with interest.

Martin Fletcher

Letter to the Editor1
Environmental health Perspective 29 November 2018 Free

The MJA–Lancet Countdown on health and climate change: Australian policy inaction threatens lives

Climate plays an important role in human health and it is well established that climate change can have very significant impacts in this regard. In partnership with The Lancet and the MJA, we present the inaugural Australian Countdown assessment of progress on climate change and health. This comprehensive assessment examines 41 indicators across five broad sections: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. These indicators and the methods used for each are largely consistent with those of the Lancet Countdown global assessment published in October 2017, but with an Australian focus. Significant developments include the addition of a new indicator on mental health. Overall, we find that Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In a number of respects, Australia has gone backwards and now lags behind other high income countries such as Germany and the United Kingdom. Examples include the persistence of a very high carbon-intensive energy system in Australia, and its slow transition to renewables and low carbon electricity generation. However, we also find some examples of good progress, such as heatwave response planning. Given the overall poor state of progress on climate change and health in Australia, this country now has an enormous opportunity to take action and protect human health and lives. Australia has the technical knowhow and intellect to do this, and our annual updates of this assessment will track Australia’s engagement with and progress on this vitally important issue.

Ying Zhang · Paul J Beggs · Hilary Bambrick · Helen L Berry · Martina K Linnenluecke · Stefan Trueck · Robyn Alders · Peng Bi · Sinead M Boylan · Donna Green · Yuming Guo · Ivan C Hanigan · Elizabeth G Hanna · Arunima Malik · Geoffrey G Morgan · Mark Stevenson · Shilu Tong · Nick Watts · Anthony G Capon

18 00789
Health services administration Letters 19 November 2018 Free

Health protection and Australian prisons, 2018

To the Editor: In 2007 and again in 2012, we highlighted in the Medical Journal of Australia1,2 the limited access Australian prisoners had to essential health protection measures. Six years on, we can only report that progress has been minimal (Box). In August 2012, the Australian Capital Territory Chief Minister announced the implementation of a needle exchange program for prisoners in the ACT; 6 years later, the ACT government retracted its commitment. Canada has recently agreed to a pilot prison-based needle exchange, with a commitment to national implementation in 2019. Human immunodeficiency virus (HIV) is still not a concern in Australian prisons, although bleach provision and condoms are still severely restricted in Queensland and the Northern Territory, and effectively not available in Victoria and Tasmania. Hepatitis B immunisation coverage continues to improve, and chronic hepatitis B infection is not increasing among Aboriginal and Torres Strait Islander prisoners.3 The availability of direct-acting antiviral treatments for hepatitis C infection for all Australians, including prisoners, has some Australian prisons already reporting treatment achievements commensurate to international treatment targets for 20304 — the term “micro-elimination” has been applied to facility by facility reduction of burden of this infection. However, despite reductions in hepatitis C in Australian prisons, the risk of transmission is ever present.5 The predictors of successful return to the community include housing, employment and maintenance of relationships;6 yet, private family (conjugal) visits are only allowed in some Victorian prisons and in one South Australian prison farm. Visits are definitely not available to ACT prisoners, since previous enabling policy was repealed in 2014. Safer sex is still an elusive aspiration for the majority of Australian prisoners and their families. Tattoo and body piercing programs are being implemented in prisons in Luxembourg and Catalonia, Spain. Despite this activity being successfully regulated in the community, there are still no verifiable reports of sanctioned programs in Australian prisons. In 2012, we questioned Australia’s commitment to protecting the health of prisoners.2 With changes in prison harm reduction programs internationally (notably, Canada) underpinned by legal challenges, we foresee that similar proceedings could have a place in finally driving reform in Australia. Box – Progress in Australian prisoners’ access to essential health protection measures Jurisdiction Changes since 2012 Australian Capital Territory Bleach available in single unit sachets; micro-elimination of hepatitis C from the only prison; private family visits ceased; support for a prison needle exchange program withdrawn New South Wales Micro-elimination of hepatitis C from several prisons Northern Territory No notable changes Queensland Still considering opiate replacement therapy; micro-elimination of hepatitis C from one prison South Australia Private visits available at one prison farm Tasmania Micro-elimination of hepatitis C from one prison Victoria Micro-elimination of hepatitis C from several prisons Western Australia Poor uptake of hepatitis C treatment

Michael H Levy · Carla J Treloar

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