Our intrepid health wrapper, Dr Lesley Russell, is still drifting delicately through powder snow in Colorado this week but her eagle eyes haven’t missed much on her way down the slopes.
Below, she fills us in on some US political developments, Colorado’s early experience with assisted dying, the ongoing struggle against measles misinformation, an interesting set of women’s health statistics from wealthy countries (including the US and Australia), and some good news out of the HIV community.
And focussing on Australia with not-so-good news, she dissects the newly-released report of the PHN Advisory Panel on Mental Health.
Lesley Russell writes:
Greetings again from Colorado where the recent snow falls have been amazing – 60 centimeters overnight and today; 140 centimeters in the past week. The snow pack is now well above average which means a good spring melt, but there are concerns that this will not be enough to overcome the consequences of the 2018 drought which has left reservoirs low and little flow in the Colorado river and its tributaries.
This week has seen a spate of announcements from Democrats, about who is running and who isn’t running for the US presidency in 2020. As I write this, the frisson is whether Joe Biden will run. If you are a political tragic you might enjoy my recent summary of the candidates and the issues on Inside Story.
One candidate is the former governor of Colorado John Hickenlooper. He’s running as a moderate (which means he is not supporting Medicare-for-All or the New Green Deal) but he has a good story to tell about what he has achieved in Colorado.
During Hickenlooper’s time in office, Colorado enacted a Dignity with Dying law. This was controversial, but it was put to a state ballot and was supported by 70 percent of voters.
Assisted dying in Colorado
Colorado passed an End-of-Life Options Act in 2016. Five other states (California, Hawaii, Oregon, Vermont, Washington) and the District of Columbia also have codified dignified death laws.
The Act allows Colorado residents with a prognosis of less than six months to live, to request and self-administer medication (typically either secobarbital or a diazepam, digoxin, morphine sulphate, propranolol compound) to end their lives.
The Act has specific requirements for patients, medical facilities and health care providers who may choose to participate in this option. The prescribing doctor and the healthcare professional dispensing the medication must provide the Colorado Department of Public Health and the Environment (CDPHE) with information which is reported annually.
The CDPHE has just released its 2018 report, which shows that, in 2018, 125 patients received prescriptions under this Act, a 72 percent increase over 2017. Sixty-six different doctors were involved. The most common underlying illness for patients was cancer (75 people), progressive neurological disorders (26), chronic lower respiratory diseases (7) and heart disease (6). Most patients were aged between 65-74 years (30.8 percent) and 75-84 years (23.1 percent). More than 86 percent of individuals who were prescribed the medication died at home.
The report outlines some problems with the required reporting: for example, it appears that not all of the 125 patients who received a prescription actually used it. Not all the required documentation was received. There is some evidence that doctors managing this issue for the first time are more likely to misinterpret or submit incomplete documentation. The law currently does not authorise the state to follow up with doctors, patients and families to obtain further information.
Measles and vaccinations – the view from the US
As measles outbreaks increase around the world – including in first world countries where pockets of unvaccinated children allow this to happen – a new research paper from Denmark has looked again at the hypothesised link between the measles, mumps, rubella (MMR) vaccine and autism.
This study involved following 657,000 children over more than 5 million person years. The results indicate that MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination. It adds to previous studies through significant additional statistical power and by addressing hypotheses of susceptible subgroups and clustering of cases.
Amid concerns in the US about measles outbreaks in 11 states this year, this week saw an opinion piece in the New York Times from the US Surgeon General, the Director of the Centers for Disease Control and Prevention, and the Assistant Secretary for Health and Human Services, which makes the case about the safety of vaccines.
This past week also saw a Congressional hearing on the impact that mis-information on social media has on people’s opinions about vaccination necessity and safety. The witnesses included a brave teenager who testified that he had gone unvaccinated until he was in high school (when he made his own decision to be vaccinated) because his mother did not trust advice from health officials.
The Upshot column in the New York Times (always worth reading) makes a good case that while social media platforms play a role in spreading misinformation, they are not totally to blame. Fears about, and resistance to, vaccination are not new; they date back to when the first vaccine was developed, and despite the rapid growth in the use of social media, flu vaccination rates and infant immunisation levels have largely remained stable in recent years.
The Upshot explores how state non-medical exemptions and attitudes to vaccine mandates (fear of “communism”) are the real problems. However Facebook, YouTube and Pinterest recently made headlines by announcing initiatives to reduce vaccine misinformation on their platforms.
Status of women’s health compared in 11 countries.
A recent report from the Commonwealth Fund compares the health of American women to that of women in 10 other high income countries, including Australia (unfortunately the results are not broken down by race, which would have produced a different picture).
Not surprisingly, but shockingly, American women’s health status, especially maternal mortality, is the worst – more likely to die in pregnancy and childbirth; highest rates of chronic disease and emotional distress; high rates of out-of-pocket costs and problems paying medical bills. But interestingly, American women have the lowest wait time to see a specialist (putting all this together, it surely means something about the value of primary care and a medical home). Only 24 percent of American women rate the quality of their care as excellent or very good.
Australia, as usual, sits somewhere in the middle on all these issues with a few exceptions that are worth pointing out.
- Australia has the highest rate of caesarian sections of any of the countries looked at (332 procedures / 1000 live births, compared to US (320) and more than twice the rates of Norway (161) and the Netherlands (162)). The statement that accompanies this graph bears repeating:
The reasons behind the wide variation observed in caesarean section rates across developed countries warrants further investigation; however, some researchers suggest it is a combination of a country’s specific health system, physician and patient preferences, cultural factors, population characteristics, and payment incentives.”
- Breast cancer screening rates in Australia (55 percent of women aged 50-69 within past 2 years) lag well behind those for Sweden (90 percent), US (80 percent) and UK (75 percent). However death rates from breast cancer in Australia, Sweden and the US are the same.
- Eleven percent of Australian women aged 18-64 report out-of-pocket costs of US$2000 or more (Australia came in third, behind the US and Switzerland), and 17 percent report they have had a problem with paying a medical bill.
On PHNs and mental health
When Paresh Dawda and I released our paper on The role of Primary Health Networks in the delivery of primary care reforms last month the expected review of mental health services had not been released.
Now the Report of the PHN Advisory Panel on Mental Health (dated September 2018) has finally been put into the public domain. Given that this is a report commissioned by the Government and that many members of the advisory panel were stakeholders in PHNs, it is likely that the language of the report is somewhat constrained. Nevertheless, it makes disconcerting reading.
I admit to being worried from the start about the idea of commissioning mental health services and I worry about the inherent tension between regional autonomy and flexibility and national consistency – health outcomes by postcode is already far too common.
Here is my summary of the key issues (and yes, I have tended to concentrate on those that are problems):
- PHNs have not been funded or directed adequately or given adequate lead times to manage the kind of changes they are being asked to implement.
- PHN funding for mental health reflects the historic underfunding of these services, it is uncertain, leading to short-term contracts, and the budget for administration costs and overheads is inadequate.
- Three years on from their establishment, there is significant variation between PHNs with respect to their organisational capability and capacity to implement mental health reforms.
- There is also significant variation in the involvement of Local Hospital Networks and the levels of engagement of GPs.
- The lack of integration of regional data sources is a barrier to obtaining a comprehensive view of population mental health needs.
- Internal PHN, and service provider, capacity needs to be enhanced.
- There is no consistent evidence for the (essential) engagement of consumers, carers, families and communities in all phases of mental health commissioning.
- Variations in the PHNs’ approaches to clinical governance affect consistency, safety and quality of care.
- Do PHNs adhere to evidence-based commissioning principles and support established models of care? Where the evidence base does not exist, what capacity and resources are available for innovation?
- There are concerns that the fragmentation of mental health services is getting worse rather than better.
- Some services (such as telehealth) might be better managed through national rather than regional commissioning.
- The commissioning and decommissioning of services must be transparent. To highlight this point, this week saw an article in the media about the commissioning of headspace services by PHNs.
- Workforce development is a central issue needing attention.
- As I have outlined previously, there is no formal mechanism to enable PHNs to learn from each other.
- There is as yet little ability to measure outcomes.
- There is a question as to whether the design of the system of governance and the level of oversight is adequate for the responsibilities and public funds entrusted to PHNs.
Pretty damning; pretty worrying. What will be done to address these issues?
The Advisory Panel also developed a Five Year Horizon Plan for PHNs and their report included a set of recommendations to the Minister that set out the actions needed for mental health reforms via primary care. So far, the only ministerial response has been to provide three years of funding, to 2021-22, to PHNs for mental health services.
There’s an excellent piece just out on the Power to Persuade blog from Karen Gardner that looks at the issue of accountability in the commissioning by PHNs of mental health services, in the light of the controversy over headspace mentioned above.
This week’s good news story
This month there was news that, for just the second time since the global epidemic began, a patient appears to have been cured of infection with HIV – following a bone marrow transplant for cancer. The news came nearly 12 years to the day after the first patient was known to be cured, a feat that researchers have long tried, and failed, to duplicate. The New York Times has a report here and an article that answers key questions here.
And just days later this success was followed by a report of a third cure.
Researchers say these surprise successes confirm curing HIV infection is possible, if difficult, with no quick fix on the horizon.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow Lesley on Twitter at @LRussellWolpe
Previous editions of The Health Wrap can be read here.
