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Maintaining the quality of colonoscopies is vital if promised reductions in colorectal cancer are to be achieved
In many ways, colonoscopy has been a transformative health technology. By allowing the early identification and removal of polyps, it reduces colorectal cancer incidence and mortality. Evidence for population screening using a faecal occult blood test and follow-up colonoscopy was based on randomised controlled studies that found a reduction in colorectal cancer mortality of 28–32% with flexible sigmoidoscopy.1 It is estimated that by 2040, the National Bowel Cancer Screening Program will prevent 92 200 cases of colorectal cancer and 59 000 deaths, using conservative modelling based on current participation of just 40%.2 These benefits are substantial, given that bowel cancer is the second highest cause of cancer death in Australia and participation in the National Bowel Cancer Screening Program is increasing.3 However, without high quality and appropriate use of colonoscopy, patients may be exposed to avoidable adverse outcomes without significant benefit. These include procedural and sedation-related complications, missed cancers, missed adenomas (hence increased risk of bowel cancer), and adverse patient experience. Further, overuse of the procedure in patients who are unlikely to benefit from it results in low value care and reduces access for patients in greater need. In order to ensure the maximum benefit to the Australian population, the Australian Commission on Safety and Quality in Health Care has developed a Colonoscopy Clinical Care Standard (www.safetyandquality.gov.au/our-work/clinical-care-standards/colonoscopy-clinical-care-standard).
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We thank Brett Abbenbroek for his contribution to the development of the Clinical Care Standard, and the Colonoscopy Clinical Care Standard Topic Working Group for their expert advice. Funding for the development of the Colonoscopy Clinical Care Standard was provided by the Australian Government Department of Health.
No relevant disclosures.
Drug allergy education and effective communication of accurate information can optimise drug allergy management and patient safety
A drug allergy label is often applied to a patient after an adverse drug reaction (ADR), usually resulting in subsequent avoidance of the drug and related drugs. Recent attention has focused on antibiotic allergy labels and the benefits of delabelling.1 But drug allergy labels, which occur in up to 35% of patient electronic health records (EHRs), encompass all types of medications, with antibiotics, opiates and non-steroidal anti-inflammatory drugs being among the most common (Box 1).2 Accurate and effective communication of drug allergy is crucial for safe prescribing, including sufficient information to enable assessment of the risk of re-exposure compared with the risk of withholding the index drug and related drugs.
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We thank Sandra Vale, National Allergy Strategy coordinator, for her contribution to the drafting of this article. We also thank Connie Katelaris, James Yun, Maria Said, Andrew Lucas, Syed Ali and the members of the Australasian Society of Clinical Immunology and Allergy Drug Allergy Working Party for their contribution to this manuscript.
No relevant disclosures.
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We thank Angela Gazey, Nuala Chapple and Jake Smith from the School of Population and Global Health, University of Western Australia, for their assistance in the preparation of this publication.
No relevant disclosures.
A cautious response to public interest in medical uses of cannabis products remains appropriate
Over the past 20 years or more, governments in many countries have struggled with how best to respond to the requests of patients, families and some doctors that they be allowed to use unapproved cannabis-based medicines to treat serious medical conditions that have failed to respond to conventional treatment.1 In Australia, parents of children with cancer or intractable forms of epilepsy have recently persuaded state and federal governments to permit access to cannabis-based products for medical use under the Special Access Scheme of the Therapeutic Goods Act.2
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We have each advised the Therapeutic Goods Administration on the evidence of the safety and effectiveness of cannabinoids in the treatment of various illnesses. Wayne Hall is a member of the Australian Advisory Council on the Medicinal Uses of Cannabis.
Clinicians need appropriate education and support in keeping pace with the genomics revolution
Media headlines stating that genetic testing for patients with a high risk of breast and ovarian cancer are now free are somewhat misleading. Clinical genetic testing for heritable, germline mutations (pathogenic variants) in two major genes (BRCA1 and BRCA2) that are associated with a high risk of breast and ovarian cancer came into Australian practice in the mid-1990s, and were offered free of charge (but not under Medicare) to appropriate patients in public clinics. Until now, testing, which has proven clinical utility,1 has mostly been offered through a network of family cancer clinics and genetics services that provide expert genetic counselling and testing of these genes in the context of familial breast and ovarian cancer.
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All of the authors are involved in a research study about the mainstreaming of genetic testing for patients with ovarian cancer, which is funded by AstraZeneca. Michael Friedlander, Kathy Tucker and Margaret Gleeson have received honoraria for educational talks for AstraZeneca; Michael Friedlander has also participated in an advisory capacity.
Objective: To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation.
Design: Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics.
Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009–2016.
Main outcome measures: Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates.
Results: The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0–100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%).
Conclusion: Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.
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Dennis Petrie is supported by Monash University and an Australian Research Council Discovery Early Career Researcher Award.
Catherine Keating and Anna Barker are employed by Medibank Private. Anna Barker receives salary support from Monash University. Chris Schilling is employed by KPMG and received consultancy fees from Medibank Private to undertake the analysis presented in this article. Stephen Wilson has previously received consultancy fees from Medibank Private in relation to development of rehabilitation in the home.
Objective: To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor–patient relationship and treatment compliance.
Design: A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor–patient relationship (ISMII).
Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February–May 2017.
Outcome measures: Descriptive statistics for searching prevalence and characteristics, doctor–patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor–patient interaction.
Results: 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6–31.0); searching improved the doctor–patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61–0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06–1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20–0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information.
Conclusion: Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor–patient interaction and was unlikely to reduce adherence to treatment.
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We thank Andrew Walby, director of Emergency Medicine, St. Vincent’s Hospital Melbourne, and Thomas Chan, director of Emergency Medicine, Austin Health, for supporting this investigation in their emergency departments in 2017.
No relevant disclosures.
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Lucy Morgan is Head of the Australian Bronchiectasis Registry Steering Committee.
Monoclonal antibody-based therapies are improving outcomes for patients with a range of cancers
Anti-cancer immunotherapy, including monoclonal antibodies to specific cell surface protein antigens, is proving to be a successful strategy in the emerging era of personalised medicine. This issue of the Journal includes the report of a retrospective study of the impact of one of the first therapeutic monoclonal antibodies, rituximab, on the relative survival of patients with non-Hodgkin lymphoma in Queensland between 1993 and 2012.1 Rituximab binds the CD20 antigen that is found on 90% of B cells, making it easier for other immune system cells to eliminate the cancerous cells (antibody-dependent cell-mediated immunity).
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Abstract
Objectives: To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology.
Design, setting, participants: Prospective inception cohort study (3-month inception period, 1 October – 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU.
Main outcomes: Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days).
Results: Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the database group (18/49, 37%) than in the clinical diagnosis group (13/83, 16%; P = 0.006).
Conclusions: When compared with the reference standard — prospective clinical diagnosis — ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.