Health services administration

To the Editor:With the release of the 2017 Australia’s Health Tracker by Socio-economic Status1 comes the latest evidence of an unjust health divide in Australia. With few exceptions, people who are more socially disadvantaged have worse health than their advantaged counterparts — a paradigm known as the social gradient of health.1 Despite increased need, socially disadvantaged individuals are less likely to access health care compared with advantaged people.2 It was refreshing, therefore, to read that the federal Shadow Minister for Health and Medicare Catherine King has placed health inequities front and centre of the Australian Labor Party health strategy, highlighting the importance of equitable prevention and public health and pledging to reduce the inequities in access to health care.3 Only 1.3% of the total Australian health expenditure is dedicated to the prevention of non-communicable diseases, much of which is directed at behavioural factors, including physical inactivity, poor diet and smoking1 — all of which are known to influence non-communicable diseases, such as diabetes, cardiovascular disease and osteoporosis.4 However, focusing primarily on behaviour ignores the wider context of health problems: the social, economic and cultural factors influencing that behaviour.5 The mounting costs of living and insecure employment increase vulnerability to non-communicable diseases. Improving the availability of affordable housing, quality employment and educational opportunities may better serve individuals at the economic margins, thereby addressing the stark inequities observed between advantaged and disadvantaged people. Dealing with these inequities would achieve discrete sectoral and health goals, providing cost-effective intersectoral cobenefits. What then is the role, for example, of the employment or educational sectors in driving the policies that address the socio-economic conditions which ultimately contribute to a healthy Australia? What is role for the health sector? The Department of Health could play a stewardship role, supporting and enabling other government agencies to manage their own sectoral goals while positively influencing health outcomes. Dealing with health inequities requires an intersectoral approach, a long term view, courageous leadership at the highest executive level, and support by an empowered public sector based on principles of fairness. Australia must act on social determinants of health and address this major problem for the health of our society.

Sharon L Brennan-Olsen · Sharon Friel

To the Editor: I write to comment on the Perspective by Wolfenden and colleagues1 on e-cigarette use by young people. In the article, the authors make regulatory recommendations for e-cigarettes based on the assertion that vaping causes young people to take up smoking — the so-called gateway theory. However, while many studies have found that adolescents who try vaping are more likely to try smoking, there is no evidence of cause and effect. The longitudinal studies described only show an association and are unable to demonstrate causality.2 An alternative explanation is common liability; that is, that young people who are more attracted to experimentation are more likely to try both products. In fact, international reviews suggest that vaping is diverting adolescents away from smoking and reducing smoking rates.3 As vaping rates have been increasing in young people, smoking rates are rapidly declining — a finding inconsistent with a gateway effect. Real world studies show that most vaping by young people is experimental and short lived and only a minority use nicotine. Regular vaping among teens is almost exclusively confined to those who already smoke. A recent analysis of five national surveys in the United Kingdom of 60 000 adolescents found that regular vaping by never-smoking 11–16-year-olds was 0.1–0.5%.4 Perhaps most important of all, Wolfenden and colleagues1 dismiss the substantial public health benefit that could result from vaping. Population studies have indicated that millions of smokers have quit using e-cigarettes and modelling studies have found a substantial net public health benefit, even using pessimistic scenarios.5 Banning wider access to e-cigarettes on the basis of an unproven risk to adolescents would prevent access to a life-saving quitting aid for millions of smokers. A better solution is to employ strategies to minimise youth access and make vaping available for adult smokers who are otherwise unable to quit smoking with conventional therapies.

Colin P Mendelsohn

To the Editor: Wolfenden and colleagues1 fail to justify the ban on the sale of nicotine-containing e-cigarettes in Australia and do not address the supporting arguments for allowing smokers to access these products.2,3 The concern that e-cigarettes may recruit young smokers justifies a regulatory response but not a ban on sales of nicotine-containing e-cigarettes to adults,3 who are thereby prevented from using these products. The authors cite a meta-analysis of studies that showed an association between the past 30-day use of e-cigarettes and combustible cigarettes;4 however, they ignore the weaknesses in the studies. First, most studies defined an adolescent e-cigarette user or cigarette smoker as one who had used either product in the past 30 days. These studies do not show that adolescents who used e-cigarettes were more likely to become daily smokers than their peers who did not use them. Second, the studies had substantial subject attrition (more than 30% in four out of nine studies) and they often poorly controlled for a shared liability to use drugs. The association was weakest in the largest and best controlled study.5 In addition, Wolfenden and colleagues make no mention of the steep decline in youth smoking rates that has occurred in both the United Kingdom and the United Sates while vaping has increased among young people.5,6 Nor do they mention that the UK’s smoking prevalence is now the same as Australia’s, in the absence of plain packaging or high tobacco tax.6 The authors’ claim that a relaxation of the ban on e-cigarette sales in Australia “has the potential for unintended harm” ignores the direct harms caused by the current ban; for example, the unregulated use of e-cigarettes, a black market, and the criminalisation of e-cigarettes users.6 Finally, even if the evidence for a gateway effect were accepted, it would, at most, justify a tighter regulation of e-cigarettes; it does not justify a prohibition on adult e-cigarette use. If it did, we would be morally obliged to prohibit the sale of cigarettes to smokers because on their argument this would be the most effective way of preventing adolescents from smoking cigarettes.

Wayne D Hall

In reply

Sze Lin Yoong · Emily Stockings · Luke Wolfenden

To the Editor:Ahern and colleagues1 explore the potential benefits and pitfalls of benchmarked reporting in the Australian context. As a binational registry of patients on renal replacement therapy in Australia and New Zealand, the Australia and New Zealand Dialysis and Transplant Registry has been producing and distributing centre-specific performance reports to renal units for over 20 years; these share many of the challenges faced by clinician-level reporting. In the past few years, this has extended to provision of an abridged version of the report on our website, containing unit-specific risk-adjusted outcome data for each dialysis and transplant unit (http://www.anzdata.org.au/v1/hospitalreport.html). The authors highlight the challenges of low case numbers resulting in statistical models that are underpowered to detect poor performance and require long observation periods that will limit timely detection of outliers and opportunities for remedial action. Co-opting statistical techniques used for quality control in other industries may present an opportunity to address these issues in the health care sector. Cumulative sum control charts2 provide a method for sequentially monitoring cumulative performance over time, which may permit early detection of poor performance and account for varying activity levels by including the number of procedures performed, rather than just a fixed time frame. Similarly, Bayesian approaches that involve updating prior probability distributions within a dynamic model may address these concerns3 and offer the conceptual advantage of explicitly testing not just the statistical difference from average but the likelihood of performance falling into a defined poor performance category. Finally, there are systems that use differing criteria for smaller and larger units.4 Ahern and colleagues discuss the potential consequences of poor performance, but omit any reference to exactly who should oversee this process. We assert that the relevant specialty or subspecialty body has a crucial role in overseeing the interpretation of reports. The detection of an outlier is dependent on the nature of the boundaries set for acceptable performance, and the vulnerability of the statistical adjustment model to bias and unmeasured confounders. Such interpretation requires detailed knowledge of the relevant field, an appreciation of the variation between centres, and substantial epidemiological knowledge.

Matthew P Sypek · Matthew D Jose · Stephen P McDonald

In reply

Susannah Ahern · Sue M Evans · Ingrid Hopper · Arul Earnest

Retrieval medicine

Noel R Eatough

To the Editor:The recent tragic suicides of young doctors have highlighted concerns regarding the welfare of trainees in our profession. The Trainee Committee of the College of Intensive Care Medicine of Australian and New Zealand (CICM) met in Melbourne in March 2017, and the recent results of the survey1 into bullying and harassment, in addition to the deaths of several junior medical officers to suicide, provided for a solemn meeting. The committee wants to highlight the factors that adversely affect intensive care medicine trainees: bullying, discrimination and sexual harassment;1 staffing and intensity as, while patients’ needs are more complex, staffing has not increased with this intensity of practice; rapid response teams, which are often under-resourced, poorly trained and undersupported; and poor workforce planning and tenuous future job security, compelling junior doctors to pursue increased non-clinical commitments without an allocated time to do so. A consequence of these factors is burnout, which disproportionately affects intensivists and is an increasingly significant risk in trainees.2 Changes in work practices, severity of illness, increased demand for limited resources and increasing intensive care unit size — problems that have recently been addressed by Corke3 — have all played a part in burnout rates. The Trainee Committee welcomes the approach of the CICM to tackle these issues.4 The college is steadfast in its zero tolerance to bullying, discrimination and harassment, and remains committed to fair and equitable access to training. The college also values the need for a reasonable balance between provision of clinical services and time for professional development, and recognises the importance of work–life balance, including part-time training and the provision of parental and other forms of leave. However, the CICM has limited ability to enforce these needs at hospital level. Finally, the CICM embraces rapid response teams, recognising the importance of an appropriately supported service, but hospitals need to respond to this need, and lack of planning and matching training with lifetime workforce demands have to be a priority for the government at all levels. Our specialty will change significantly in the next decade or so. We chose intensive care because we enjoy the work we do and find the challenge it provides rewarding. We must ensure that the next generation of intensivists can meet this challenge too.

Alun T Ellis · Sandra Lussier · Sarah A Yong

To the Editor: Retinal screening is crucial to the prevention of vision loss from diabetic retinopathy. The recent National Eye Health Survey highlighted a gap in screening rates between Indigenous Australians (aged ≥ 40 years) and non-Indigenous Australians (aged ≥ 50 years),1 providing a foundation on which to target future eye health services. While acknowledging the budgetary and logistical constraints of such a large-scale study, we are concerned that another at-risk group — younger adults with type 2 diabetes who are aged 18–49 years — was not included in the National Eye Health Survey. The past two decades have seen a global increase in the incidence of type 2 diabetes in youth and young adults, with younger age being an independent risk factor for the development of diabetic retinopathy.2 In Australia, about 130 000 people with type 2 diabetes who are aged < 50 years are registered on the National Diabetes Services Scheme.3 However, there are no population-level data available regarding retinal screening rates in this age group. A decade ago, a survey of young Australian adults with type 2 diabetes (aged 16–35 years) reported a 55% retinal screening rate.4 Given the small, self-selected sample, this is likely an overestimate and compares unfavourably with the non-Indigenous rate of 78% reported for adults aged ≥ 50 years in the National Eye Health Survey.1Moreover, our qualitative research has shown that young adults aged 18–39 years who have type 2 diabetes face different psychosocial challenges and barriers to retinal screening compared with their older counterparts aged ≥ 40 years.5 Younger adults with type 2 diabetes require targeted, tailored intervention, which can only be provided if accurate, population-level data are available for this group. As Foreman and colleagues1 acknowledge, diabetic retinopathy is the leading cause of vision loss in working age adults — a situation with potential for considerable social and economic burden. The absence of current eye examination data for younger Australians with type 2 diabetes increases the risk that their needs will be neglected in future evidence-based policy and program delivery initiatives. We urge the Australian Government and other stakeholders to extend future population-level surveys (and other research and policy initiatives) to include all adults with diabetes.

Amelia J Lake · Jessica L Browne · Jane Speight

In reply

Joshua Foreman · Stuart Keel · Mohamed Dirani

To the Editor: We read with interest the recent article by Bonevski and colleagues1 calling for targeting of tobacco cessation interventions to high-risk populations, including prisoners. People who cycle through prisons in Australia smoke tobacco at a rate five times that of the general population,2 and suffer disproportionately from smoking-related morbidity and mortality.3 However, the suggestion by Bonevski and colleagues1 that smoke-free policies in prisons “impact on reducing smoking” is unfortunately a case of misplaced optimism: although these policies reduce smoking in prisons, they have almost no effect on long term smoking behaviour in people who cycle through prisons. Research in the United States shows that about 60% of people released from smoke-free prisons resume smoking on the day of release,4 and 97% relapse within 6 months of release.5 Preliminary findings from a cross-sectional survey we have conducted with 114 ex-smokers released from smoke-free prisons in Queensland paint a similar picture, with 72% of participants reporting relapse on the day of release. Smoke-free policies in Australian prisons are an important public health initiative and should be supported. However, alone they are insufficient to reduce the remarkably high rates of smoking, and of related morbidity and mortality, in the vulnerable populations who cycle through these institutions. There is an urgent need for development and rigorous evaluation of smoking cessation and relapse prevention interventions targeting people released from prison in Australia. Building on the findings of a recent trial in the United States,4 we have recently been awarded funding from the Victorian Health Promotion Foundation to undertake a double-blinded, randomised controlled trial of an intervention designed to reduce relapse to smoking among people released from smoke-free prisons in Victoria. We hope that our study will provide new evidence to guide future efforts to reduce tobacco-related harm in this population. We echo Bonevski and colleagues’1 call for a comprehensive policy shift aimed at reducing tobacco use among disadvantaged populations in Australia. However, prison smoking bans alone are insufficient. Investment in evidence-based efforts to prevent smoking relapse after release from prison will be critical to reduce tobacco-related health disparities in this profoundly vulnerable, marginalised population and realise this important public health opportunity.

Cheneal Puljević · Stuart A Kinner

In reply

Billie Bonevski · David P Thomas · Robyn L Richmond