Healthy one day, sick the next- the issue of Diagnosis Creep

 

An article by Hugo Wilcken in the Medical Journal of Australia InSight page turned me onto the discussion over ‘Diagnosis Creep’. Essentially this is coined as a negative term for the change in definitions of diseases which causes an increase in those diagnosed with that disease which prior to the change would be otherwise considered as not having it. An example would be osteoporosis where in 2008 a new definition was adopted and instantly changed the affected population of women from 21% to 72%! Similarly changes to definitions have created ‘pre-‘ conditions in the diseases of diabetes and hypertension. Wilcken contends that what makes these changes diagnosis creep is that they do not offer health benefits as the treatments do not successfully aid to overall health or well-being.

Some factors have been forwarded to explain diagnosis creep. One such idea is that of the ‘pre’ classification of diseases. Therefore, you may not clinically have the disease, but you are at risk of contracting it. Another theory is that the expert panels who decide on what clinical factors are needed to lead to a diagnosis are made up of clinicians who specialize in their field. These experts, in order to be able to treat effectively, tend to be more inclusive than exclusive when re-examining factors and therefore lessen the threshold for diseases.

Then there is the nasty side of diagnosis creep. There seems to be a pervasive concern that pharmaceutical companies have a wayward hand in expanding the population with certain diseases in order to increase sales of medications for that disease. The MJA InSight article discusses this as ‘Big Phrama’ and contends that some ‘expert panel’ members are sponsored by pharmaceutical companies- leading to potential conflicts of interest. A similar argument was made in an article in The Conversation in 2016.

No matter what the reasons diseases are being re-defined to include more patients an article in the Australian Prescriber magazine sums up the reason for this post:

Health professionals should be more aware, and patients and the public better informed, about the controversy surrounding many contemporary definitions of disease. Diagnostic criteria are not set in stone – they are regularly changed, often with the best of intentions, but are also often rigorously challenged because of the potential for unintended harms.

In Australia the issue has been seen as serious enough that the NPS group has developed an entire campaign entitled “Choose Wisely” to inform and attempt to tackle the need for certain tests, treatments and procedures. Readers of this blog can also follow the Choose Wisely campaign on Twitter at @ChooseWiselyAU.

Before the MJA article I had not known about diagnosis creep, nor the controversy surrounding it. However, the issue does make sense. All healthcare professionals should be conscious of how and why patients are being diagnosed with diseases and what treatments are being given. While I do recognize the need for disease management and appropriate medications I also recognize that we can easily over-medicate and the elimination of any unneeded treatment would be valuable, particularly in the elderly. I applaud the works of Wilcken and the NPS at serving as a checks-and-balance system in this most important area.

References

MJA InSight: Diagnosis creep: the new problem in medicine

The Conversation: Resisting expanding disease empires: why we shouldn’t label healthy people as sick

Australian Prescriber: Caution! Diagnosis creep

NPS Medwise: Choosing Wisely Australia

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Telehealth to combat Australia’s growing demand for healthcare?

An article in IT Brief tackles the topic of how Australia is going to tackle the increased need for healthcare moving forward. According to a report in the Newcastle Herald Australian men are ranked in the top three countries worldwide in life expectancy, while women are in the top fourth. This is great news for Australians, and can cause sleepless nights for policy makers. The World Health Organization reports that currently Australia as of 2014 spends 9.4% of Gross Domestic Product on healthcare, that equates to approximately $4,357 per person. With the baby boomers expected to reach their senior age this figure is surely going to rise.

The IT Brief discussed several

items relating to IT and healthcare. One such discussion was over the My Health Record program by the federal government. I have previously discussed the My Health Record in another post. I believe it is a vital and important forward step in advancing the Australian healthcare system.

Another item discussed was the use of smartphone apps and other personal IT devices to aid in chronic disease management. This is a field that is sure to improve as our tech-savy population ages.

But the item discussed that interested me was that of individuals being able to visit with a doctor via an online medium. This was described in the article as a potential way for people to access medical care without needing to wait in a doctor’s office and would allow access in rural areas. In Australia we have a similar system in place in rural areas. However, looking to rely on this as a measure to markedly decrease the reliance on in-person healthcare is suspect.

While visual clues and interviews are important in assessing health concerns palpation, auscultation and the ability to have the patient in front of you make up much of both doctors’ and nurses’ assessments. Additionally, many presentations we see in hospital that have come from GPs requires further acute assessment not available in a doctor’s surgery: ultrasounds, CT scans, and urgent blood tests. These items would not be available to a patient sitting in their lounge room speaking with a doctor over the internet.

If there are chronic and stable conditions which only call for simple follow-up then online medical consultation would be fine. However, I wonder if that is not being done already? My concern is that moving forward the need for acute in-person healthcare will only increase. And with that increase will be the need for more acute beds in hospitals and more healthcare facilities to deal with demand.

Your thoughts?

References

IT Brief: Digital tech – the answer to Aussie healthcare’s biggest ailments?

Newcastle Herald: Australia about to lose top spot in this world health ranking

WHO: Australia

Australia, better healthcare than America- absolutely!

stethoscope-840125_1280

 

I came across this article and had to write about it. Marie Shieh, a doctor trained in America and now practices in Australia, has written a piece for the The Telegraph. In it she states emphatically that Australia’s health care is better than Americas. Full stop, no qualifiers. And as a former consumer and provider of America’s healthcare system I can agree.

Confession: my road to becoming a registered nurse started because of poor quality healthcare that my father received before his death. We were poor, not living on the streets poor, but we did not have a lot of money. My parents owned a printing business, and we did not have health insurance. When I was young my father was diagnosed with diabetes, then cancer and finally a heart condition. Because we did not have health insurance all of these medical conditions were treated very conservatively and without extensive examination. I believe, as a consequence of that, he suffered a major heart attack and died prematurely.

Now I know that he contributed to his condition with smoking and being overweight. But a lack of medical care significantly contributed to his death. From that moment on I was destined to be in healthcare, despite my attempts to move away from it. I have worked in palliative (hospice in America) care in the U.S. and now work in the Australian hospital system.

We have an amazing healthcare system. Yes, it is over-budget. Yes, there is over-crowding and never enough beds in our hospitals. Yes, people do (at times) come into emergency departments for things that could just as well be handled at their own doctors. But our system allows for every Australian the chance to have optimal health and to be free of medical issues, or at least have them treated to the best that our medical and nursing care can offer without fear of being unable to pay for such treatment.

I have always said that the Australian healthcare system would not work in America. The current push to repeal ‘Obamacare’ as it is called exemplifies this. Americans feel that they should be self-sufficient. And that is not necessarily a bad thing. Health insurance plans are out there to assist with costs. However, the American attitude of “if you can’t afford it we won’t pay for it” still leads to a class-based healthcare system. If you have money then you have health. As a nurse and believer in healthcare that is not right. Health is part of Maslow’s basic needs, and I feel it should be offered as a right just as security in the form of police and safety with firefighters.

maslow-pyramid

Maslow’s heirachy of needs- image source

Alas I do not feel that America will change their ways. The core beliefs of self-sufficiency go all the way back to revolutionary times. I am proud to say I am an Australian registered nurse. I am proud to say that the healthcare I and the thousands of other dedicated workers allows everyday Australians peace of mind and can allow us to continue to prosper.

 

The Telegraph: Trump is right about Australian health care, an American doctor in Australia says

Privacy concern or valuable tool: all Aussies can have an e-health record, would you?


The ABC network has written that with a new surge in federal funding the My Health Record project looks to provide all Australians with the ability to have an electronic health summary. This is a follow-on from other E-health projects trying to establish similar results. While I can understand the apprehension noted by some with regards to privacy and sharing of health information from a healthcare worker’s perspective it is a great leap forward.



In my history as a registered nurse I remember the days before electronic health records. The nature of our health system in Australia means that an individual can present at numerous public and private health institutions without any ability of those institutions knowing prior medical treatment. This is a safety concern for the patient at worst and could potentially prolong the time for effective treatment in the least.


With the implementation of the local electronic health record if I am looking after a patient who has visited another health facility within the same area, state, or even nationally connected the doctor and I can see previous treatments and tests, allowing for more accurate diagnosis and treatment. Expanding this nationally would allow those visiting or recently moved to the area to have better quality care by allowing information sharing.


It is also better for the GP. Now general practitioners must rely on discharge summaries for information about hospital treatment. However, with the electronic record the GP could access more complete information from hospital visits, aiding in their continuation of care at home. A GP could also review and place information for patients on the record in case they travel or are too sick to speak for themselves, vital information which could save their life.


There is always a potential for abuse of the system. However, I would trust that the powers-at-be would design safeguards to prevent unauthorized information sharing of electronic health records. I, for one, will be happy to welcome this advancement in Australian healthcare. According to the ABC report individuals would be allowed to ‘opt out’ of the program.

ABC news: Everyone to have a digital health record

The tragedy of Manchester brings out the true colours of emergency services

As a relatively short-lived member of an emergency department I can say I have never been through a horrific event like that which occurred in Manchester, UK. But the spirit behind all of the nurses in the six hospitals lives within all of us.

By default emergency nurses and doctors are trained to take a patient with little background and through systematic assessment treat the priorities to bring about the best possible outcome.

Nurses learn to act selflessly and tirelessly to get the job done. I am proud to consider myself a member of an elite fraternity called emergency room nurses. Absolute praise and respect to all those who helped in the aftermath.

Should the government regulate family size?

A report in the Medical Journal of Australia has toyed with the idea of poor families being encouraged to limit the size of their families through discouraging more than a set number of kids.

Professor Jones cited the increase of children within the system over the last two decades. Professor Jones stated “We need to ask politically charged questions, such as should we be developing policies that encourage disadvantaged families to have fewer children”.

I have spoken before about professional healthcare bodies weighing in on political matters. However, a case (however thin) could be made that this is a health issue. There is a a far more concerning component to this topic.

History has shown that regulating reproduction has caused anger and disdain from society. A prime example is abortion, either by surgery or via the ‘morning after’ pill. Any attempt to limit a woman’s ability to choose how many children she has would most likely cause similar back-lash. What would be the penalty for violating the birth maximum, withdrawal of funding? Then the burden of care will still rest on the government via social services, hospitals or other agencies.

And what is called ‘low income’? Centrelink funding? Inability to buy a house? Lack of steady income? There are many Australians teetering on low income. Where would society be willing to draw the line? And what would happen if a family who had over the set maximum of children found themselves in that low-income category?

I think you understand my position on this. While it may be true that the number of children burdening the government’s budget has grown Australians have steadfastly held the belief of a ‘fair go’ and to remain non-judgemental.

Your thoughts?

Reference

Sydney Morning Herald: Should poor people have fewer children? Medical Journal of Australia

Comparison of nurses and doctors registered in Australia

doctors-nurse-group-nurses-set-hospital-47095908

Quick Facts

  • According to 2016 AHPRA data there were 342,221 nurses and 104,102 doctors practicing in Australia. This means more than three nurses for every doctor.
  • The gender of doctors was roughly equal as 58.2% were male, compared to the female-dominated nursing which encompassed 12% identifying as male.
  • Investigating age practitioners in both groups showed a majority were under 50- 65.6% of nurses and 72.9% of doctors. Both groups also showed the highest number of practitioners were in the 30-34 year age range.
  • The number of nurses state-by-state was not suprising with NSW showing the largest share (27.4%) followed by Victoria (26.3%) and Queensland (20.1%).
  • NSW showed a low density of people per kilometer but the highest number of nurses compared to other states and territories.  

The inspiration for my post this morning was a tweet by the Australian Health Practitioners Association (AHPRA) for International Nurses Day which stated that nationally there were 375,528 registered and enrolled nurses in Australia currently. This includes practicing and non-practicing nurses. An advantage of AHPRA becoming the central body for clinical registration is to allow for national statistics for registrants which can be compared. So I investigated some statistics regarding nurses in Australia and how those statistics compare to equivalent doctor numbers.
Both sets of figures were taken from comparable AHPRA reports; for nurses it is the Nursing and Midwifery Board of Australia registrant data, and for doctors it is the Medical Board of Australia registrant data. Both reports were for the 1st of October to 31st of December 2016 date range and all figures excluded practitioners who were not practicing their particular clinical area at the time of the report (therefore excluding non-practitioners). The results were surprising in some areas, while expected in others:
A total of 342, 221 nurses were practicing in Australia during the report, while only 104,102 doctors were licensed at the time. Therefore for every doctor there were over three nurses licensed. The gender gap for doctors was quite narrow with 58.2% being male, however nursing continues to be a female-dominant profession with only 12% being listed as male. This, however, shows improvement from the year I graduated in which less than 10% of nurses were male.
Age was also an interesting read. To allow for easier comparison I broke the data into two age ranges: under 25 to 49 and 50  to 80+. These ages seem to represent two classic working demographics, prime working years (U25-50), and those approaching retirement. A common statement heard amongst critics of the current nursing workforce is that the nursing cohort is ageing, however according to the reports investigated nurses over 50 only accounted for 34.4% of workers with the vast majority (65.6%) under the age of 50. Doctors showed even more youth with 72.9% being under the age of 50. Nurses over the age of 65 were double that of doctors (4.2% vs 1.9%). The largest decade-cohort was identical for both at 30-34 with nurses representing 13.5% and doctors representing 14% of this bracket.
A state-by-state comparison of nurses showed, to me, an expected result. The highest number of nurses was found in New South Wales (NSW) with 27.4%, Victoria seconding (26.3%) and Queensland in third-place with 19.7%. The other states and territories accounted for 26.6%. Doctors showed similar trends. This trend closely coincides with population statistics taken in September 2016 which showed NSW having 32.0% of the population of Australia, Victoria having 25.2% and Queensland again in third with 20.1%.
An insight into the difficulty of providing healthcare in Australia could be identified by looking at population density during the same September 2016 period. The Australian Capital Territory (ACT) ranks as the most dense state with 171.40 persons per kilometer meaning that the residents would be in close proximity to health facilities. Victoria is second with a density of 26.11 persons per kilometer showing more difficulty of providing healthcare services in a less urban environment. New South Wales shows that each kilometer only holds 9.52 persons, providing for vast rural area to cover.
So what does all of these numbers mean? Well there are over three nurses for every doctor in Australia. Both are showing younger cohorts with the largest number being in the 30-34 year old range. Within nursing this is a shift from the threat that the nursing population is becoming older and therefore going to retire soon. Medicine is showing to be an equal mix of male and female, however nursing is still female-dominated.

The numbers of nurses by state closely match that of population. However, when compared to density the ACT showed less nurses were required to take care of a highly dense state area showing a specifically urban landscape. While in my home state of New South Wales we had the highest number of licensed nursing staff and a very sparse 9.52 persons per kilometer, meaning a large rural component when compared to the ACT.

All in all the numbers renew my faith that nursing in Australia is not currently a profession of elderly women as it is sometimes portrayed, but a vibrant profession which attracts young (and male) talent. I am proud to be called a registered nurse, and I hope that all 375,528 licensed nurses can say the same.

What do you think of these figures?

 

References

Nursing and Midwifery Board registrant data

Medical Board of Australia registrant data