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Information science

Health services administration Perspectives 1 August 2022 Open Access

Making everyone count: it is time to improve the visibility of people with disability in primary care

Without data on access to, or quality of, the care for people with disability, it is impossible to determine drivers of health inequities, and to develop evidence-informed policies to improve care and track progress towards reducing health inequities

Jodie Bailie · Nicola Fortune · Julie Gordon · Richard C Madden · Gwynnyth Llewellyn

Mja2 51650
Health services administration Letters 18 July 2022 Free

Patient‐reported outcome measures (PROMs) to guide clinical care: recommendations and challenges

To the Editor: We read with interest the article by Agarwal and colleagues1 outlining the recommendations from the Health Services Research Association of Australia and New Zealand for implementing patient‐reported outcome measures (PROMs) to guide clinical care. The article regrettably fails to acknowledge that most of the commonly used PROMs — largely developed without direct patient participation — may merely provide a patient‐rated version of a measure that nevertheless reflects the clinician’s or researcher’s, not the patient’s, perspective.2,3 Importantly, “patient‐reported” conveys only that the measurement instrument — usually a scale or questionnaire — is completed by the patient. The emphasis is placed on the source of the information (ie, the patient) rather than on its content. It does not automatically imply that the information thus obtained is necessarily of value or relevance to the patient. As an attempt to shed light on this issue, our group elaborated a classification system for PROMs according to the degree of patient involvement in their development:2 patient‐generated PROMs — a type of PROM developed entirely from the patient perspective, as at all stages of PROM development the researchers are themselves patients; patient‐centred PROMs — a kind of PROM that explicitly incorporates, to a greater or lesser extent, patient priorities, given that patients themselves codeveloped the PROM jointly with other stakeholders (eg, clinicians); patient‐valued PROMs — a variety of PROM developed without patient input but valued by most patients because it reflects, at least in part, their priorities; and patient‐irrelevant PROMs — a type of PROM developed entirely without patient participation, whose contents are evaluated as not relevant by patients themselves. Fortunately, the epistemic injustice of disregarding the patient’s perspective in PROMs development is being progressively abandoned, and there seems to be a growing consensus that patients should be significantly involved — through truly participatory methods — in developing any new PROM.2,4,5 Without genuinely incorporating the patient’s perspective in PROMs development, PROMs collection will not contribute to a true and meaningful involvement of patients in their health care.

Joan Trujols · Santiago Duran‐Sindreu · Maria J Portella

Mja2 51614
Indigenous health Narrative review 4 July 2022 Open Access

Interrogating the intentions for Aboriginal and Torres Strait Islander health: a narrative review of research outputs since the introduction of Closing the Gap

We need intellectual investment that prioritises Indigenous ways of knowing, being and doing, and acknowledges the historical and contemporary colonisation, dispossession and racism that continue to have an impact on health outcomes today

Michelle Kennedy · Jessica Bennett · Sian Maidment · Catherine Chamberlain · Kate Booth · Romany McGuffog · Bree Hobden · Lisa J Whop · Jamie Bryant

Mja2 51601
Information science Letters 6 June 2022 Free

Reading the fine print: Medicare telehealth changes to disadvantage rural and remote populations

To the Editor: The rapid uptake of telehealth has been a cornerstone of the response to the coronavirus disease 2019 (COVID‐19) pandemic, and has ensured the provision of essential health care despite restrictions and lockdowns. Although not new technology, telehealth has dramatically increased in prominence and received broad acceptance by doctors and patients alike. Given its success, the Australian Government has confirmed the permanent retention of multiple telehealth item numbers within the Medicare Benefits Schedule (MBS).1 However, it is concerning that this announcement also contained the fine print that the long‐standing MBS incentive for providing telepsychiatry consultations to rural and remote patients will be abolished. This is despite patients in rural and remote communities experiencing well established difficulties accessing health care and having poorer outcomes than their metropolitan counterparts.2 Telehealth consultations have occurred in psychiatry since well before the COVID‐19 pandemic, and have filled an important gap in the workforce by increasing services available in rural and remote areas.3 Video‐based consultations are particularly suited to psychiatry as the key skills of history taking, mental state examination, and psychotherapy do not require physical proximity. Delivering diagnostic assessment and psychological treatment via telehealth have long been demonstrated to be effective and tolerable.4,5 The MBS item number 288 was introduced in 2011 as an adjunct billing code that attracted a 50% loading for psychiatric consultations conducted via telehealth for patients located in a rural or remote setting, aged care facility, or Aboriginal health service. This loading incentivised bulk‐billing of these telehealth assessments. The deletion of this item number from 1 January 2022 will likely result in two adverse consequences: i) fewer telepsychiatry consultations to rural and remote locations will be bulk billed, and ii) telepsychiatry appointments that previously were only available for rural and remote patients will increasingly be offered to metropolitan patients. This will ensure fewer and less affordable options. The cessation of the rural loading for telehealth assessments is a retrograde step that is likely to further entrench long‐standing inequities in both access to care and patient outcomes for psychiatric patients who do not live in the cities. The 288 item number should be reinstated or replaced with an alternative funding mechanism to ensure bulk billed consultations continue to be available for rural and remote patients.

Michael J Weightman

Mja2 51529
Endocrinology Letters 4 April 2022 Free

The Virtual Inpatient Diabetes Management Service: COVID‐19 brings the future to inpatient diabetes management

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1 The management of large numbers of COVID‐19 inpatients with diabetes has been challenging. People with diabetes are a vulnerable population who are at risk of adverse outcomes from COVID‐19, with a two‐ to threefold likelihood of death compared with people without diabetes.2 Hyperglycaemia is associated with higher risk;3 hence, good glucose management is desirable. Exacerbation of diabetes by dexamethasone therapy, used to treat patients with COVID‐19, and the development of steroid‐induced hyperglycaemia in non‐diabetic patients present further challenges. Traditional models of care relying on referrals from parent teams to an endocrinologist (or registrar), who then reviews the patient daily to chart insulin, are inefficient and impractical for this situation. We have developed a virtual inpatient diabetes management service (vIDMS) as a means for a small diabetes team to manage COVID‐19 inpatients with diabetes. The success of this model has revolved around an electronic medical record, electronic inpatient prescribing, a diabetes dashboard, and videoconferencing communications. The recording of all glucose measurements (including point of care) within the electronic medical record has enabled the systematic capture and display of hospital‐wide glucose data on a diabetes dashboard (Box). This also allows viewing and filtering by any variable in the electronic medical record, such as ward, age, biochemistry (including formal laboratory glucose and glycated haemoglobin), development of hypoglycaemia, prescribed medications (including corticosteroids), and COVID‐19 status. Therefore, COVID‐19 patients with diabetes or hyperglycaemia are easily identified. The vIDMS, comprising of a consultant, a registrar and a diabetes educator, reviewed patients with COVID‐19 and hyperglycaemia on a daily basis, using the dashboard and electronic medical record, by sharing a screen on a videoconferencing platform. Remote management was undertaken through the electronic medical record, including medication and insulin dose adjustments. Communication with ward staff and patients with COVID‐19 through the electronic medical record, or by telephone or video, was undertaken when needed, including for diabetes education. Entry into the COVID‐19 wards and usage of personal protective equipment was not required. In the 6 weeks to 5 September 2021, 112 COVID‐19 patients with diabetes were thus managed in Westmead Hospital (median age, 62 years; range, 23–91 years), with up to 40 patients reviewed per day. Necessitated by COVID‐19, the future of inpatient diabetes management is now here. With one‐quarter of patients in metropolitan hospitals having self‐reported diabetes4 but insufficient specialised diabetes staff to provide individual management, the vIDMS will become a significant part of the wider model of diabetes care for large hospitals.5 While initial and intermittent face‐to‐face contact remains valuable to build a relationship and discuss relevant issues, and careful review of medical records is necessary to understand perturbations in glucose levels (eg, fasting, missed medication), the vIDMS enables daily specialist care for large numbers of patients with diabetes by a small team. The health system needs to facilitate its wider application for the management of both COVID‐19 and non‐COVID‐19 patients with diabetes in hospital. Box – Diabetes dashboard showing hospital‐wide glucose data for patients with coronavirus disease 2019 (COVID‐19)

N Wah Cheung · Amanda Hor · Tien‐Ming Hng

Mja2 51456
Mental health Letters 17 January 2022 Free

Suicide by young Australians, 2006–2015: a cross‐sectional analysis of national coronial data

To the Editor: In their study examining the suicide deaths of 3027 young Australians during 2006–2015, Hill and colleagues1 reported that nearly 60% of cases had experienced mental health problems during their lifetime, and around 75% of deaths were of young males. We would like to draw attention to another important statistic within these data. Specifically, 4.6% of males who died by suicide in Australia had a diagnosis of autism spectrum disorder (ASD). This is alarming, considering that the prevalence of males with ASD in Australia is estimated to be only 1.3%.2 For males in the study age range (ie, 10–24 years), the prevalence ranges from 1.2% to 3.3%, with the highest prevalence in the 10–14 year bracket. Nonetheless, the apparent high incidence of suicide by males with ASD is consistent with recent research indicating a three‐ to nine‐fold increased risk of suicide among people with ASD compared with the general population.3,4 The increased suicide risk in ASD may be explained by the high incidence of comorbid psychiatric disorders among this population.5 Indeed, in one national cohort study from Denmark, over 90% of people with ASD who attempted or died by suicide had another comorbid mental health condition.3 In addition, it is important to note the low rate of suicide reported among females with ASD (0.4%). This finding is inconsistent with large international studies that report significantly increased incidence of suicide among females with ASD compared with females in the general population, with rates similar to or exceeding that of males with and without ASD.3,4,5 Females with ASD may be underrepresented in the data presented by Hill and colleagues due to lower recognition of ASD among females or to diagnostic overshadowing, whereby ASD is overlooked in favour of other more apparent psychiatric diagnoses (eg, anxiety, borderline personality disorder, depression). Finally, we highlight the fact that there is no systematic procedure or requirement in Australia for asking about or reporting ASD diagnoses within the emergency department or hospital admission systems. Plausibly, ASD is inadequately captured in data concerning health and mental health profiles, health service system access, suicide attempts and deaths in Australia.

Darren Hedley · Mark A Stokes · Julian N Trollor

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