Perceptions of economic hardship and implications for illness management: a survey of general practitioners in western Sydney

The present study aimed to understand the options available to general practitioners (GPs) practising in Western Sydney to help patients experiencing economic hardship to manage their illnesses and the implications of these findings for policy

A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness

BACKGROUND The Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers. METHOD We interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease. RESULTS Patients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes. CONCLUSIONS In order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.he Serious and Continuing Illnesses Policy and Practice Study (SCIPPS) is a National Health and Medical Council of Australia (NHMRC) funded program (no: 402793) conducted at the University of Sydney and The Australian National University and administered by the Menzies Centre for Health Policy

Identifying the science and technology dimensions of emerging public policy issues through horizon scanning

Public policy requires public support, which in turn implies a need to enable the public not just to understand policy but also to be engaged in its development. Where complex science and technology issues are involved in policy making, this takes time, so it is important to identify emerging issues of this type and prepare engagement plans. In our horizon scanning exercise, we used a modified Delphi technique [1]. A wide group of people with interests in the science and policy interface (drawn from policy makers, policy adviser, practitioners, the private sector and academics) elicited a long list of emergent policy issues in which science and technology would feature strongly and which would also necessitate public engagement as policies are developed. This was then refined to a short list of top priorities for policy makers. Thirty issues were identified within broad areas of business and technology; energy and environment; government, politics and education; health, healthcare, population and aging; information, communication, infrastructure and transport; and public safety and national security.Public policy requires public support, which in turn implies a need to enable the public not just to understand policy but also to be engaged in its development. Where complex science and technology issues are involved in policy making, this takes time, so it is important to identify emerging issues of this type and prepare engagement plans. In our horizon scanning exercise, we used a modified Delphi technique [1]. A wide group of people with interests in the science and policy interface (drawn from policy makers, policy adviser, practitioners, the private sector and academics) elicited a long list of emergent policy issues in which science and technology would feature strongly and which would also necessitate public engagement as policies are developed. This was then refined to a short list of top priorities for policy makers. Thirty issues were identified within broad areas of business and technology; energy and environment; government, politics and education; health, healthcare, population and aging; information, communication, infrastructure and transport; and public safety and national security

Spondylarthropathies (including psoriatic arthritis): 244. Validity of Colour Doppler and Spectral Doppler Ultrasound of Sacroilicac Joints Againts Physical Examination as Gold Standard

Background: Sacroiliac joints (SJ) involvement is a distinctive and charasteristic feature of Spondyloarthritis (SpA) and x-ray is the test routinely used to make a diagnosis. However, x-ray reveals late structural damage but cannot detect active inflammation. The objective of this study was to assess the validity of Doppler ultrasound in SJ. Methods: Prospective blinded and controlled study of SJ, in which three populations were compared. We studied 106 consecutive cases, who were divided into three groups: a) 53 patients diagnosed with SpA who had inflammatory lumbar and gluteal pain assessed by a rheumatologist; b) 26 patients diagnosed with SpA who didn't have SJ tenderness and had normal physical examination; c) control group of 27 subjects (healthy subjetcs or with mechanical lumbar pain). All patients included that were diagnosed with SpA met almost the European Spondyloarthropathy Study Group (ESSG) classification criteria. Physical examination of the SJ included: sacral sulcus tenderness, iliac gapping, iliac compression, midline sacral thrust test, Gaenslen's test, and Patrick s test were used as gold standard. Both SJ were examined with Doppler ultrasound (General Electric Logiq 9, Wauwatosa WI, USA) fitted with a 9-14 Mhz lineal probe. The ultrasonographer was blinded to clinical data. Doppler in SJ was assessed as positive when both Doppler colour and resistance index (RI) < 0.75 within the SJ area were present. Statistical analysis was performed estimating sensitivity and specificity against gold standard. The Kappa correlation coefficient was used for reliability study. Results: 106 cases (53 female, 55 male; mean age 36 10 years) were studied. There were no statistical differences between groups related to age or sex. Physical examination of SJ was positive in 38 patients (59 sacroiliac joints). US detected Doppler signal within SJ in 37 patients (58 SJ): 33 of them were symptomatic SpA (52 SJ), one of them were asymptomatic SpA (1 SJ) and one was a healthy control (1 SJ). The accuracy of US when compared to clinical data as gold standard at subject level in the overall group was: sensitivity of 68.6% and specificity of 85.7%, positive predictive value of 70.5% and negative predictive value of 84.5%. A positive likelihood ratio of 4.8, a negative likelihood ratio of 0.36 and a kappa coefficient of 0.55 were achieved. Conclusions: Doppler US of SJ seems to be a valid method to detect active SJ inflammation. Disclosure statement: The authors have declared no conflicts of interes

Geology: Canyon cutting on a grand time scale

The age and evolution of the Grand Canyon have been subjects of great interest and debate since its discovery. We found that cave mammillaries (water table indicator speleothems) from nine sites in the Grand Canyon showed uranium-lead dating evidence for an old western Grand Canyon on the assumption that groundwater table decline rates are equivalent to incision rates. Samples in the western Grand Canyon yielded apparent water table decline rates of 55 to 123 meters per million years over the past 17 million years, in contrast to eastern Grand Canyon samples that yielded much faster rates (166 to 411 meters per million years). Chronology and inferred incision data indicate that the Grand Canyon evolved via headward erosion from west to east, together with late-stage (~3.7 million years ago) accelerated incision in the eastern block

Addressing general practice workforce shortages: policy options

• There is an ongoing shortage of general practitioners in Australia, accompanied by a decline in the popularity of general practice as a career choice. • Many factors influence the career choice of junior doctors and medical students, including role models, the quality of clinical attachments during training, remuneration, and flexibility of training and working hours. • Evidence-based strategies that could increase the number of doctors choosing general practice as a career include longer and higher-quality general practice attachments during medical school and the early postgraduate years, and emphasising the positive aspects of general practice, such as flexibility. • General practice would become a more attractive choice if remuneration was in line with hospital specialties

Hospitalisation and death: no co-payment required

Out-of-pocket costs are creating health problems for less well-off patients, write Angela Beaton, Tim Usherwood, Stephen Leeder and Lesley Russell • OUR recent study for the Menzies Centre for Health Policy found that Australian doctors believe their patients are experiencing increasing financial hardship – with serious consequences for their health, and even death. These findings highlight the imperative of dealing with the rising out-of-pocket costs that discourage patients from complying with treatment and medication regimes and force many Australians to choose between paying essential costs – rent, electricity and food – and accessing health care.&nbsp; Despite the universal coverage of Medicare, increased rates of bulk billing, free public hospital care and subsidised prescription medicines, Australians face some of the highest co-payments for health care within OECD countries. These co-payments have risen as a proportion of total medical costs faster in Australia than in any comparable country over the past ten years.&nbsp; More than one in every six dollars spent on health care is paid directly by consumers. That amounts to more than $15 billion a year, more than double the amount covered by private health insurance. Out-of-pocket costs comprise 17.7 per cent of health spending in Australia, a higher proportion than in thirteen out of twenty OECD countries, including the United States. This growing financial burden is borne disproportionately by those who can least afford it, severely compromising the ability of people with chronic illnesses to get the treatment they need, undermining the equity of Medicare, and giving short shrift to the Australian notion of a fair go. Not only are these payments high, but the way we attempt to compensate for them, through a complex and confusing series of safety nets, is inefficient and discriminatory. Yet the issue receives little political or policy attention. Our research highlights the seriousness of the consequences. In a recent survey of general practitioners practising in western Sydney, most reported encountering patients whom they perceived to be experiencing economic hardship, and they thought that the problem had grown worse over the preceding twelve months. The shocking finding is that the majority of GPs believed that at least some of their patients had either experienced a deterioration in health, been admitted to hospital or died as a consequence of their failure to take their medicines as prescribed because of cost. Our survey didn’t explore the details of issues like patients’ admission to hospital or death, and there are no Australian data to show that increased co-payments lead to these adverse outcomes. But previous research has shown that there was a substantial and sustained drop in the number of PBS prescriptions filled following the 21 per cent increase in PBS co-payments in 2005, highlighting the impact that cost can have on use of medications.There is international evidence to show that increases in out-of-pocket payments disproportionately reduce adherence among low-income patients, particularly for those with chronic conditions. A recent US study found higher hospitalisation rates and increased length of hospital stays for elderly patients within a year of co-payment increases. The effects were magnified among people living in areas of lower income and education and among people who had hypertension, diabetes, or a history of heart attack.What can GPs do about the economic problems of their patients? Most patients seem willing to talk to their doctor about their financial difficulties; in other cases, doctors realise there are problems when patients ask for consultations to be bulk-billed, for a delay in payment, or are reluctant to take medications or see a specialist because of cost. That’s encouraging, and our research shows that GPs try to be responsive. But the options they have to help patients manage their illness and its costs are limited.&nbsp; General practitioners most commonly offered assistance to their patients in several ways. They can bulk-bill consultations and making referrals to bulk-billing specialists. They can provide drug sample packs free to patients. Or they can change medications to reduce the cost to the patient (for example, by prescribing combination or generic medicines where possible). Less commonly, GPs prioritise medications for their patients, offer a referral to a social welfare or assistance agency or give their patients money to purchase essential medicines. The direct dispensing of sample packs raises several concerns about the how medicines are used by patients, particularly if drug samples are supplied with limited labelling and inadequate instructions about dosage, administration, storage and possible adverse effects. And sample packs are obviously not a sustainable option over years of chronic illness. Australian policy makers need to recognise the fact that out-of-pocket costs and co-payments result in perverse incentives, with the net effect of shifting the cost burden from the affluent and healthy to the poor and sick. The poor spend a higher proportion of their household income on health care costs, and sick people, on average, are poorer. When people are not able to access needed care, their health deteriorates; the result is an increased in expense for the individual, the health care system and the economy as a whole. This inequity is further compounded by the current focus on fee-for-service and the way the Medicare safety net works to the benefit of the well-to-do. Australia invests heavily in the management of chronic illness, funding specific primary care services and hospital-based programs and providing subsidies for expensive prescription medicines. But much of this effort is potentially undone by the inability of a significant number of patients to afford the co-payments for their multiple medicines.&nbsp; A policy response is needed – perhaps based on the Closing the Gap PBS co-payment measures which are in place for Indigenous Australians with or at risk of chronic illness, and which commenced on 1 July last year. In the absence of such an approach, the delivery of real health care reforms that also represent real value for taxpayers will founder. •Angela Beaton is a research fellow at the Menzies Centre for Health Policy at the University of Sydney. Tim Usherwood is a general practitioner, professor and head of the Department of General Practice, Sydney Medical School – Western, at Westmead Hospital. His clinical practice is at a community-controlled Aboriginal medical service in western Sydney. Stephen Leeder is a professor of public health and community medicine and director of the Menzies Centre for Health Policy at the University of Sydney. Lesley Russell is a research associate at the Menzies Centre for Health Policy and the US Studies Centre at the University of Sydney and a senior fellow at the Centre for American Progress in Washington, DC.Photo: Anthony Hall/ iStockphot