Health services administration

To the Editor:Advance care planning (ACP) promotes conversations about future health care, in case a person should lose capacity for decision making. Advance care directives (ACDs) provide written documentation of these conversations. Yet, although the Australian Medical Association advocates ACP within routine clinical practice,1 ACD completion rates remain low.2 While recognising numerous barriers to ACP, including patient, practitioner and health care system factors,3 a dedicated ACP Medicare Benefits Schedule (MBS) item number was mentioned in a number of general discussions at the 2016 Advance Care Planning Australia national conference (Melbourne, 15–17 November) as a potential incentive to increase the use of ACDs in primary care. In general, we support this recommendation. Health economics tells us that where there is a shortage of a specific service, as could be argued for ACP, the supply of this service will increase under fee-for-service payment.4 Patients are less knowledgeable about prices, services and associated benefit than providers; however, the existence of an agency relationship5 (where the patient assigns decisional authority on the basis that they have less information) between general practitioners and patients would facilitate ACDs from which patients are most likely to benefit. On the other hand, there is some risk that financial incentives will motivate GPs to do more than is optimal or desired, especially if the service is priced above standard consultation fees. There is also an opportunity cost; if GPs are providing more ACP services they will have less time to provide other primary care services. However, the risk of financial incentives may be mitigated by the non-financial barriers to ACP (fear or reluctance of patients, insufficient GP skills or organisational factors). Therefore, in designing policies to increase uptake, especially where financial incentives are the driver, a multifaceted approach should be considered. Service reimbursement mechanisms and potential barriers should also be balanced against maintenance of ACP values such as patient autonomy and informed decision making. As a starting point, a two-tiered MBS item number could be beneficial, the first item billable for initiation of ACP and the second used for revisitation of ACDs after a given time period (eg, annual review). Subsequent review of policy responses, including patient and medical practitioner input, will be needed to ensure appropriate directions surrounding MBS billing. Further accompanying strategies may be required to address non-financial barriers to ACP uptake.

Amanda Pereira-Salgado · Jennifer J Watts

To the Editor:With reference to Batterham and colleagues,1 we applaud the call to better align research funding to disease burden. We also address this shortfall in the leading killer: cardiovascular disease (CVD). The federal government deserves praise for establishing the Medical Research Future Fund (MRFF), doubling funding by 2023. This augurs well for the future, but right now, we face an interregnum while the MRFF builds and the National Health and Medical Research Council funding flatlines. Every year, CVD claims the lives of 45 093 Australians,1 accounting for more than one in three deaths. The direct cost of caring for people with CVD in 2008–09 was $7.7 billion per year (or 12% of the total health budget),2 making it the costliest disease group of all. With the current budget at over $120 billion per annum,3 and assuming that CVD continues to cost 10–12% of the health budget, it is likely that the current cost is well over $12 billion per annum.3 The most recent data show that CVD deaths increased for the first time in 4 decades in men aged 55–64 years,3 an increase associated with the rising rates of obesity and diabetes.3 This reflects the unanswered questions related to heart health, which are ripe for exploration. Meanwhile CVD research is funded substantially less than the equivalent disease burden of cancer, receiving about 13.5% — cumulative frequency of about 22% — of the National Health and Medical Research Council total funding between 2008 and 2014.4 A clear consequence is that CVD research suffers from brain drain, as emerging researchers seek sectors where funding is more available. This workforce crisis was highlighted by a recent Australian Cardiovascular Alliance survey, where 65% of CVD researchers say they would leave the sector if funding is not secured. Australian CVD research is of international standing, providing the highest returns of any disease group on research investment, an extraordinary $8 in health benefits for every $1 spent.4,5 The need for a committed workforce skilled in heart research is clear. Funds from the MRFF must be invested in research that reflects the health priorities and disease burden facing the nation, particularly where the market is failing. Such research is an investment not a cost. In 2017, the Heart Foundation will boost research investment by an additional $9.3 million. While substantial for the only major health charity supporting heart research, this is a drop in the ocean to what is needed. Proportionate investment will ensure that the great legacy of cardiovascular research in Australia is retained.

Garry LR Jennings · Jaye Chin-Dusting

To the Editor:Acute stroke management has undergone major transformations with the advent of endovascular thrombectomy, but there remains a large gap in care between metropolitan and rural Australia. While metropolitan stroke centres are currently redesigning their services to expedite intervention for patients eligible for endovascular thrombectomy, rural and remote areas are still lagging behind with basic stroke therapies. Alteplase therapy for acute stroke within 4.5 hours remains the bedrock of treatment. Nevertheless, presenting to a hospital that has the capability to facilitate this treatment is not as simple for a rural patient as for a metropolitan patient. Distance and isolation are major factors in preventing access to treatment, as is lack of local expertise. In addition, there is a paucity of neurologists working in rural Australia. Where Melbourne and Sydney boast one neurologist for every 25 000 persons, rural Australia ranges from one in 100 000–200 000 people (Costello, C. Australian and New Zealand Association of Neurologists Workforce Survey. Sydney: ANZAN; 2016 [unpublished internal report]). There are rural physicians who are skilled in the management of acute stroke, but there remain barriers and reluctance to use thrombolysis within this group.1 The impact of stroke also significantly burdens the rural Indigenous community. In the Northern Territory, the Indigenous population have a three times higher incidence (307 per 100 000 people) of stroke, a younger age of onset (10 years earlier), higher case fatality, higher stroke recurrence and higher cost of lifetime stroke compared with non-Indigenous and metropolitan patients.2,3 Due to remoteness and delays in transfer, Indigenous people often miss the opportunity for acute therapy. Telestroke services are currently being used in certain parts of regional Australia; they are an effective, safe and efficient method of bringing the metropolitan neurologist to the rural patient’s bedside.4 However, more resources must be invested to make this a service that covers all corners of the country. In addition, it is necessary to implement better recruitment strategies for neurologists to rural centres and stroke-specific public health campaigns that are culturally appropriate, and to increase funding for research to design innovative and creative ways to provide comprehensive care to remote patients. Urgent action is required now; otherwise, an isolated part of our country and community will only face greater challenges over time.

Prashanth Ramachandran · James Burrow

To the Editor:Biobanking involves the collection, processing, storage and distribution of biospecimens and data, and, in recent years, it has rapidly evolved to become an integral component in biomedical research.1 Biobanks may range in complexity from a single researcher storing their own material to large stores of material used by multiple researchers. This diversity has complicated the standardisation of biobanking practices,2,3 sometimes compromising biospecimen quality and storage capacity4 and the security of funding. In turn, irreproducible research results, poor biospecimen access and decreased public confidence may ensue.4 Therefore, New South Wales Health Pathology — a statewide clinical diagnostic service — has adapted and launched a Biobank Certification Program in conjunction with the Canadian Office of Biobank Education and Research and the Canadian Tissue Repository Network, where the program has been operating successfully for 4 years.5 This voluntary program aims to improve the quality of biobanking practices and raise standards through the provision of education modules and document templates. To encourage participation, the program is free for NSW biobanks and associated pathology laboratories for the first year. Nominal fees will subsequently apply for non-NSW Health organisations. Certification requires the biobank or pathology leader to register details of the biobank and complete (with team members) up to nine pertinent education modules, submit a declaration of compliance to adhere to best practices and upload key documents for auditor review. Moreover, biobanks may also opt to be listed on a publically available biobank locator. The program is designed as a first step towards improving the quality of biobanks for stakeholders, including researchers, multicentre trials, ethics committees, funders and the public. Current biobank practices are diverse, making a formal accreditation system impractical for some biobanks to undertake. It is envisaged that the program — subject to evaluation and uptake of staff education modules — may provide a foundation for a future accreditation program. Further information is available at https://nsw.biobanking.org.

Jane E Carpenter · Amanda Rush · Candace Carter

To the Editor:In our study,1 we engaged the services of a third party online panel to recruit survey participants. Pre-existing information on private health insurance status, smoking status and exercise participation for those completing the survey was provided by the third party, who has now confirmed that the data initially labelled as “private health insurance” were actually “smoking” status. All other demographic information used in our analysis was collected directly from participants completing the online survey. We initially reported a positive association between private health insurance and being bulk-billed (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.09–1.78). However, the discovery of this labelling error better explains the positive association we initially reported for those data; it is smokers who are more likely to be bulk-billed than non-smokers, not those with private health insurance being more likely to be bulk-billed than those without private health insurance. Retaining these data on smoking status in our model, and adding in the correct data for private health insurance status, we observe that those with private health insurance are less likely to be bulk-billed than those without it (OR, 0.63; 95% CI, 0.51–0.77). The remaining relationships between individuals’ characteristics and the likelihood of being bulked-billed are unchanged from those reported previously. The results from the updated multivariate logistic regression analysis are provided in the Box. Box – Odds ratios for factors associated with bulk billing (n = 2467) Multivariate regression statistic Wald χ2 = 234.63 (P = < 0.001). Bars represent 95% confidence intervals (CIs). For each category, except age, the base factor appears without a 95% CI and straddles the line at 1. The number of respondents included was reduced by ten due to six missing observations for age and four missing observations for concession card status. * P = < 0.05 compared with the base factor.

Richard De Abreu Lourenco · Patricia Kenny · Marion R Haas · Jane P Hall