• A terrific piece bringing some much-needed perspective to discussions about mental illness, especially in the wake of recent murders. By Dr Tanya Ahmed, a registrar in psychiatry and a principal of the health and communications consultancy RaggAhmed.

• More than a million premature deaths across 30 OECD countries could be prevented each year if income inequality was reduced. That’s the best guess of a meta-analysis of studies involving around 60 million people, reported in the BMJ. The authors note that there are many caveats to their findings, including a lack of evidence from developing countries, but say their results have “potentially important policy implications for population health”. Meanwhile, I’m heartened to read that a fellow Crikey blogger is also putting inequality on the public agenda.

• When the law meets public health – Simon Chapman, professor of public health at the University of Sydney, considers the implications of a recent High Court judgment. It dismissed a duty of care negligence claim against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.

• Investigating the ties between drug companies and doctors – A group of researchers from Australia, Canada and the US have done an indepth analysis of disclosures of pharmaceutical sponsorship of gifts and educational events, as has been required of Medicines Australia members since 2007. They conclude that the disclosure does not go far enough and also give some interesting examples of how companies are wooing doctors. Novartis, for example paid flights, accommodation, food, beverages, and conference registration fees for six ophthalmologists to attend a two-day conference in Spain, at a cost of AUD$10,993 per person. For those who follow this field, it will come as no surprise that the researchers include Ray Moynihan, Lisa Bero and David Henry. The other authors are Jane Robertson and Emily Walkom from the University of Newcastle.

Will this further increase the inequities in access to good health and to health services? Or will it help close these gaps?

It doesn’t seem such an unreasonable ask when we have so much evidence that those who are most likely to have health problems are least likely to have access to useful health care.

A study published in the latest Australian and NZ Journal of Public Health provides yet more ammunition for this line of questioning.

Researchers from the ANU and University of Newcastle used data from a 2004 survey of 10,905 women aged 53 to 58 to examine the relationship between socioeconomic status and health service use.

Given that poorer and more disadvantaged groups are generally more likely to have chronic diseases and other health problems, you might expect them to use health services more often.

Not so. While GP use was roughly the same between the wealthier and the poorer, the better off women were more likely to report having used dental services, specialists, allied health practitioners, and alternative health providers.

The researchers say their findings support experts who have questioned the private health insurance rebate, and suggest that it is adding to inequities by enabling wealthier women to access allied health services, often important in the management of chronic diseases, that poorer women without insurance could not afford.

“The pattern of findings suggests that inequalities in care are to some extent shaped by the health care system itself, where out-of-pocket costs and private care influence access,” the researchers said.

“International findings are in line with these conclusions – inequity in ambulatory medical and dental care in universal systems is found to be greatest in countries where private health insurance and direct private payments play some role in access to services.”

The researchers note that their findings don’t prove that poorer women are being under-treated as their study could not rule out the possibility that advantaged women are being over-serviced. “Nevertheless,” they said, “this in itself could still be considered inequitable in that health expenditure is not being distributed according to need.”

The researchers conclude that their findings “suggest unfairness and inefficiency in the allocation of services as those who are sickest and hence potentially have the greatest capacity to benefit from health care, are not those most likely to receive it.”

Meanwhile, the Australian Healthcare and Hospitals Association has just issued this release, putting pressure on the AMA to join its stance opposing the private health insurance rebate.

It says: “The private health insurance rebate is a grossly inefficient means of supporting private health care and would deliver much greater gains to the community if spent directly on health services and infrastructure. AHHA calls on all health groups to unite in advocating for the re-direction of the private health insurance rebate funds into public hospitals and community-based care.”

Now wouldn’t that be something – imagine if the closing the gaps question was asked, not only by Health Ministers, but by powerbrokers like the AMA…what a difference that might make.

Dr Sumitra Ananda, a cancer specialist in Melbourne, is hoping the Federal Government acts on the new findings.

She writes:

“The recent report in the MJA by our group supports the fact that the National Bowel Cancer Screening has the potential to save lives and decrease mortality. The first indicator of this is the dramatic shift in stage distribution between those that were diagnosed through the program and through symptomatic presentation.

Bowel cancer is the second most common cancer in Australia and also second in terms of mortality.

We have known from large randomised controlled trials that there is a potential to reduce mortality by 16-33%.

Breast cancer on the other hand, ranks lower in terms of mortality in Australia but has an established widespread screening program targeting women aged 50-69.

The current program has had a limited roll out to those aged 50, 55 and 65 and has only one screening with no re screening offered.

It is crucial that the government fully roles out the program with rescreening which could potentially save lives and ultimately save cost.

Participation is also a key to the success of a program and comprehensive communications campaign to maximise participation are necessary. The main reasons are likely to be the lack of awareness of the benefits of screening and reluctance or embarrassment to collect and send in a stool sample.

The study also suggests the apparent lack of uptake amongst the socially disadvantaged sections of the population. This may be due to lack of understanding, lack of interest  a study showed that people from more economically deprived areas had less interest in pursuing the test) or access (not the case in our study).

Another consideration would be that these individuals are undergoing initial screening but then not pursuing follow up or have difficulty accessing colonoscopy.

Given the potential impact of the screening program and its potential to save lives, the government must consider the complete roll out of the screening program and support the resources needed to sutain it.”

Professor Mark Harris, from the UNSW Centre for Primary Health Care and Equity,  says there is enough evidence, from this and other studies, to suggest that efforts are needed to ensure lower SES groups participate in screening and are able to access related procedures.

He writes:

“The findings of the study in the MJA are interesting but we need to keep three things in mind:

Firstly there is not necessarily evidence of a social gradient in colorectal cancer incidence (i.e. a sliding scale of incidence getting lower as income increases).  There was, however, a social gradient in male bowel cancer mortality in 2000.  The poorest 60% of the population had 1.2 to 1.3 times the colorectal cancer mortality of the richest 20% in men, but not women, aged 25-64 years (AIHW 1998-2000).  This suggests that we may already have had a problem even before the National Bowel Cancer screening program.

The second consideration is that though the study shows that there may be a social gradient in screening – with a bigger proportion of cancers detected by screening in high SES groups (25/605= 4.1%) compared with lower SES groups (7/443=1.6%) – the numbers involved are small.

Thirdly, the pilot CRC screening study showed that there was also a social gradient in the proportion of patients who tested positive who then subsequently had a colonoscopy.   Thus the pilot predicted that there may be a social gradient both in uptake of screening and subsequent colonoscopy of positive cases.  This was not due to lower rates of presentation at GPs (as rates of presentation at GPs were higher in lower SES groups).

Thus on balance we can infer that there is a social gradient in screening (both FOBT and colonoscopy).  This is all consistent with studies overseas that have shown that more educated and richer people respond to initiations to faecal occult blood testing (FOBT) screening (McCaffery K et al J Med Screen 2002; 9: 104-8).

This suggests:

We need to improve the uptake of screening in low SES groups
This may be done by improving the invitation.  The current letter is formal and complex and is unlikely to motivate poorly educated patients.  The content should be simpler and based on health promotion theory.

We should also involve GPs more actively, for example by sending mailed invitations from practices to encourage patients, especially males in poorer areas.  Invitations should be tailored to encourage different groups of patients (Myers RE Prev Med 1990; 19: 502-14).

We need to address barriers to colonoscopy amongst positive patients
Significant socioeconomic barriers to colonoscopy clearly remain.  Despite poorer patients being more likely to see their GP following screening, they are less likely to have a colonoscopy than richer patients.”

That is one worrying implication from a study just published in the Medical Journal of Australia.

Researchers sought to examine the initial impact of the national bowel cancer screening program which offers faecal occult blood testing to those aged 55 or 65.

They reviewed the data on bowel cancers diagnosed between May 2006, when the program began, and June 2008 from a database involving 19 hospitals. The good news is that cancers detected through screening tended to be at an earlier stage than those diagnosed as a result of patients presenting for testing because of symptoms.

The worrying news for anyone concerned about equity is that almost two-thirds of the patients whose cancers were detected through screening were from wealthier backgrounds. Somehow, I don’t think this means that wealthier people are at increased risk of developing the cancer; it is much more likely to mean that the poorer groups are less likely to access screening.

Professor Ian Olver, ceo of Cancer Council Australia, has filed this analysis of the study:

“The recent report on the impact of bowel screening in Australia by analysing patients who present for surgery for colorectal cancer confirms the ability of the program to save lives.

As with studies from other countries, patients who are screened present with earlier stage disease which is more likely to be cured.

The study showed a disparity between low and high socioeconomic groups. Those from lower socioeconomic groups are less likely to have been screened.

Whilst this has been reported from other studies, potential solutions are not as well researched. It is known that certain subgroups like the culturally and linguistically diverse communities and Aboriginal communities will need culturally appropriate translations of information about screening. The access of remote populations may be an issue.

However what of the majority of people in lower socioeconomic groups? A recent American study has shown that educational level is a key factor, because it influences the provision of information about screening by healthcare providers (Ye J et al Cancer Epidemiol Aug 28 epub before press).

Clearly GP’s and other providers have an important role in encouraging participation in screening.

However, the major issue remains that given the proven ability of a bowel screening program to save lives, Australia still only has a one off bowel testing program rather than a full screening program.

There is no rescreening, which should occur every 2 years, and bowel screening kits are only mailed to 50, 55 and 65 year olds. Too many Australians, of all socioeconomic groups, are missing out on a program that could save 30 lives each week if fully implemented. It is urgent that the Government completes the role-out of bowel screening.”

Croakey continues:

The other worrying note from the study is the authors’ comment about the lack of evaluation of the screening program. They wrote:”…no resources have been allocated to determine the program’s ultimate impact on bowel cancer incidence or mortality”.

If true, this seems a remarkable oversight – to roll out a national program without having in place a proper evaluation process. Is this really the case?

We’re not even close – and if you’re expecting anything meaningful to happen before 2020, you’re just not paying close enough attention.

That’s  the assessment of Professor Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney.

And he thinks the Federal health reform bandwagon now visiting a hospital near you is just a distraction from the main game.

He writes:

“As I’ve expressed in an editorial in next week’s Medical Journal of Australia, this ‘consultation’ process is a major distraction.

What is clear is that the Government (assisted by the final report of the National Health and Hospitals Reform Commission) is rapidly retreating from any serious reform agenda.

Medicare Select, the reform previously known as ‘Option C’ (i.e. competitive national social insurance) has been sent to the back-blocks of Woden for a well-earned period of long-service leave. Regional health providers (Option B) are not on the agenda either.

Inevitably, a future (and somewhat braver) Government will be forced to revisit the issue of genuine health reform (in about 2020). At that time it will dust off the NHHRC interim report and have another look at a
financing system that had some real chance of changing the way that health care is delivered in this country.

In health, as in most human endeavours in the modern world, you get the health care system you pay for. If you pay for disconnected services, a narrow focus on acute care and one-off (i.e. fee-for-service) procedures
and other interventions – then that is what you’ll get.

The really neglected areas of chronic disease management, dental care, mental health, indigenous health, youth health and coordinated aged care will remain at the bottom of the pile.

The Government has already demonstrated its real (political) priorities through its major new investments in acute care hospitals, cancer care and reducing surgical waiting lists.

While the major economic stimulus package prioritised the retail sector (do we really need two plasma screen TVs in every Australian home?) and basic educational infrastructure, the health services and medical research sectors were obviously low priorities.

In the meantime, this round of hospital-centric public relations events will keep everybody chattering till we all quit for Xmas.

Clearly it is designed principally to soften us up for another round of public ‘hospital’ reform (i.e. senior Woden officials telling the States to get their act together).

Any one who has sat through “the (powerpoint) presentation’ that goes with these hospital-based events will realise rather quickly that we are not on the precipice of major ‘health’ reform.

There is no serious discussion about changing how the money flows or opening up the sector to a new breed of regional or national health care providers.

The most likely outcome for the post-2010 election period is some more money, a lot more talk and the same old divided Federal-State delivery system.”

It’s not surprising, of course, that magazines like Australian Doctor, Medical Observer or the latter’s new Practice Nurse tend to slant their coverage towards the perceived interests of their readers. Any sensible media organisation selects stories, writes them and displays them with the audience firmly in mind.

But one downside of silo-based publishing is that it leads to silo-based coverage of health issues, whose limitations become more apparent as we move towards an era of team-based, multidisciplinary care.

The dream of my colleague and I was that our new magazine would have a multi-disciplinary readership, and thus would cover stories in a way that didn’t give any particular weight to any particular professional perspective. That way, the stories might really be about health, rather than health professionals.

In this day and age, our magazine will probably remain a pipe dream; you don’t hear of too many new publications starting up. But I’d like to think that Croakey offers a forum for discussion across disciplines and sectors.

So I was most interested to receive a note on the “thorny issue of interprofessional practice” from Associate Professor Ann Larson, Director of the Combined Universities Centre for Rural Health, in Geraldton.

She was responding to a new study, led by researchers with a long interest in the potential of medicine reviews to reduce adverse events and improve care (including Libby Roughead from the Sansom Institute at the University of South Australia).

The study found that when GPs and pharmacists collaborated on home medication reviews for heart failure patients, the patients were less likely to end up in hospital than those who had no such review. The study was testing what happens in the real world – being based on retrospective analysis of patient records – rather than as part of a randomised controlled trial.

But for Ann Larson, the study has raised at least as many questions as providing answers.  She writes:

“Roughead’s retrospective study of the medical records of veterans with heart failure found that that a formal pharmacist intervention, in the form of home medication reviews and other consultations between the pharmacist and GP, was associated with reductions in hospitalizations.  This is consistent with other studies that have found pharmacist collaborative care to be effective.

What interests me the most is that the study also contributes to a larger debate of the value of inter-professional practice and its role in health care reform, but as such raises many questions.

How far can we generalize the experience of patients with GPs who have elected to seek pharmacist input?  In a small study I was involved in, a committed GP made at least some change in almost all patients’ (84%) medications following a home medication review (Quirke et al 2006).

However, are all GPs as receptive to pharmacists’ input?  And are patients who could benefit from a home medication review equally or more likely to see a GP who initiates collaborative care as those who do not?  If home medication reviews were mandated for certain conditions, would there be the same impact on prescribing patterns?

Another question is what causes the association between collaborative care and reduced hospitalizations?  Is it improved prescribing habits or more informed and motivated patients?  The answer will influence how these observed benefits could be extended to all Australians.

If GP’s prescribing habits are affected, then it may be that pharmacists need only conduct home medication reviews on a small of patients, but have more detailed feedback which will promote best practice prescribing.  On the other hand, if home medication reviews are effective because the pharmacist and patient communicate better than the patient does with his or her GP, then other health professionals or even trained lay people may be able to give medication education to patients with equal results.

Home medication reviews are still fairly rare in Australia.  Only 5% of this study of veterans had one.  If they were to be expanded, a number of other issues would become important.  Again, in our little study we found that while the GP was very satisfied with the program, local pharmacists felt that it was of limited financial or professional value, especially in circumstances where there is only one or two pharmacists and a requirement for constant presence at the business.

If the demand increased to the point that some pharmacists would derive most of their income from conducting HMRs, would the independent relationship between the pharmacist and GP be compromised?  Would their need to be a code of conduct to resolve situations where there was a difference of opinion or an error by either party?  Nor should we forget the patient?  What is the appropriate role for a patient and should HMRs be promoted to patients rather than to the GPs?

And finally I cannot help but speculate on the impact in rural and remote areas.  I have already mentioned the problems for the solo pharmacist.

But many small towns and remote communities lack a resident pharmacist altogether.  If HMRs are to be encouraged as an effective model of inter-professional care then it will be necessary to explore HMRs by telephone or with the assistance of another type of health worker being the eyes (and even ears) for the distant pharmacist.  If provision in the fee structure is not made for HMRs by distance, rural and remote residents will lose out again from benefiting from health care reform.

It is axiomatic that two professionals from complementary but distinct disciplines will provide better care than one professional.  The fact is that doubling the number of health professionals will be a more expensive service.  Understanding what features of collaborative care result in health gains are critical if we are to afford the better health care that we all want.”

(Quirke J, Wheatland B, Gilles M, Howden A and LARSON A. 2006. Home Medicines Review: do they change prescribing, and patient and pharmacist acceptance? Australian Family Physician. 35(4):266-267.)

The PM cited Australian research, recently published in the New England Journal of Medicine and reported in Crikey,  which found, he said, “that a commonly available treatment for fractures of the bones of the spinal cord was in fact no better than doing nothing at all”.

The PM said the Government was “keen to explore in conjunction with private health insurers and our research community” an NHMRC suggestion that treatments, therapies and devices which are not backed by evidence should be evaluated.

In the light of the PM’s enthusiasm for ensuring that health funding is well spent, I wonder whether he and his office are familiar with the work that was being done along these lines by the Royal Australasian College of Surgeons in evaluating surgical techniques.

Professor Guy Maddern, a surgeon who has been a driving force behind this work, writes of his great frustration at the Government’s apparent lack of support for the work:

“The recent publications in the New England Journal of Medicine describing the results of vertebroplasty highlight the problem of introduction of new surgical technologies.

Whenever a new procedure is assessed, particularly in its early stages, it is often difficult to prove that it is a superior step forward than existing technologies. This is in part because it is difficult to conduct the trials necessary to prove benefit.

Rather than rejecting a procedure because the evidence fails to be compelling, these two recent publications in the New England Journal of Medicine highlight the need for careful and assessed introduction of new technologies and procedures into surgical practice.

It is a great shame that the Australian Commonwealth Government does not greatly value assessment of procedures, particularly if they are not associated with a new Medicare item. While great efforts are put into assessing introduction of new drugs, substantial efforts are put into assessing new devices, much less effort and energy is put into the assessment of new procedures which often represent an alteration, which may be significant, of existing procedures.

It has been a great disappointment to the Royal Australasian College of Surgeons that the Commonwealth Government has not felt the need to continue to support the Australian Safety and Efficacy Register of New Interventional Procedures in Surgery.

This organisation, run by the College of Surgeons, attempts to look at new procedures that are introduced without the necessity for new Medicare item numbers. It may be that the alteration of a length of bowel, an angle of suturing or the use of existing devices in new and novel ways can bring enormous benefits but also potentially enormous harm to patients.

This desperately needs to be assessed and reported on, but explaining this to the Government at this time is a difficult and frustrating experience.

The reporting of this recent study highlights the difficulties in assessing new technologies but does not excuse the process from occurring. Hopefully it will provide further evidence to the health authorities that such activities are desperately needed within our health system.”

More info about the scheme is available in this British Medical Journal article.

Writing from Washington, health policy analyst Dr Lesley Russell says the studies are big news there, especially with the Presidential focus on health reform. The devices industry will fight hard to retain a multi-million dollar market, she says:

“It is very interesting to look at the response to the publication of these studies in the US, where one of the arguments raging around the health care reform legislation under consideration in the Congress is government funding of comparative effectiveness research and the use to which the data generated might be put.

President Obama and health and economic policy experts have been calling for just these kinds of studies as a means of controlling health costs and ensuring better health outcomes and the House bill has $1.1 billion to establish a Center for Comparative Effectiveness Research.

Opponents see this as Big Brother, in the form of the government entering the health arena, making decisions that will deprive patients of choice, ration health care and result in ‘socialized medicine’.  The UK National Institute for Health and Clinical Excellence (NICE ) is definitely not seen as nice by these people, who are apparently happy to see decisions about what treatment they get made on the basis of bank balance or the profit motives of their health insurer.

The number of vertebroplasty procedures in the US has doubled in the past six years.  Last year 73,000 people had the treatment which costs $2,500 to $3,000 plus $1,000 – 2,000 for an MRI.  This procedure cost Medicare (the government-funded health care program for people aged 65 and over) $21 million.  The total US market in  vertebroplasty had a value of about $45 million in 2008 and is projected to grow annually at a rate of 13.5 percent.

There is even less data on the effects of kyphoplasty, which involves pumping the vertebra with a balloon to restore its shape before injecting cement, and which has a much larger market, estimated at more than $500 million a year.

But this is now where the US situation is headed, with the industry already out in the media emphasizing how kyphoplasty is different.

There is a comparative study of the two procedures underway, funded by the manufacturers, but results are apparently some way off.  There are some ten US medical device companies who are involved in this field, and the early indications are that they will not cede this profitable arena without a tough fight.

In the meantime, who should make the decisions about continued funding of this treatment and on what basis?

One of the researchers on the US paper has said that people who want vertebroplasty should still be able to get it – but only if they enter a clinical trial that collects data on every case.”

• Lesley Russell is Menzies Foundation Fellow at the Menzies Centre for Health Policy University of Sydney/Australian National University and Research Associate, US Studies Centre, University of Sydney

Straight Statistics, according to its website, aims to:

• Draw attention to the inaccurate reporting of statistics in the media, and encourage better standards by training and example.
• Ensure that Governments follow the Code of Practice on the use of official statistics and the guidance issued by Sir Gus O’Donnell in February 2009.
• Monitor the use by local government, advertisers and industry of claims based on statistical or numerical information.
• Examine the statistical basis of claims made in scientific and medical journals, in the interests of greater clarity and sounder reasoning.

Straight Statistics, which was launched just a few weeks ago, has been set up with a Grant for Research and Innovation from the Nuffield Foundation.

What’s  particularly interesting is the group behind the campaign.

The board of directors include:

• Lord Lipsey (Chairman)
• Nigel Hawkes, freelance journalist  (Director)
• Professor Sheila Bird, MRC Biostatistics Unit, Cambridge
• Simon Briscoe, Statistics Editor, Financial Times
• Dr Ben Goldacre, Guardian columnist and author of Bad Science
• Dr Helen Joyce, Britain Correspondent and International Education Editor, The Economist
• Martin Moore, Director, Media Standards Trust
• Professor David Spiegelhalter, Winton Professor of the Public Understanding of Risk, University of Cambridge.

Nigel Hawkes, the organisation’s director, was quoted in a British Medical Journal news story saying that the initiative “grew out of a conviction that statistics are often misused and that public confidence in them is low.”

“The worst abuses appear to be in government departments,” he told the BMJ. “The same figures are used by one group and ignored by others.”

Mr Hawkes, a freelance journalist who writes for the BMJ, Times, and Sunday Times, previously believed the worst offenders to be newspapers but has since found that there is “not a huge amount of evidence” for statistical misuse by journalists.

Who says that journalists don’t care about truth-in-publishing…