14 minute read
The risk of not taking risks
There is nothing new about risk but as the SARS CoV2 has shown, decision-making becomes more complex in a crisis, writes Dr Michael Watson.
So why is it that two experts can give different opinions about the same situation when using an identical statistics-based risk assessment?
The simple answer is that risk assessment is an objective mathematical process but riskbased decision making is more complex and requires subjective assessments of benefit vs risk.
The mistake leaders often make is considering the risks of a situation without first considering the benefits. Let’s take patients attending their GP during the COVID-19 crisis as an example. The single focus on the risks of catching the SARS CoV2 virus resulted in patients being too frightened to attend their GP. People with chronic diseases didn’t keep up their usual GP checkins and missed opportunities to prevent minor illnesses from becoming major ones. Were patients undervaluing the benefits their GP’s oversight? I don’t think so, I think people were simply giving in to fear and failing to put the risks into perspective. Government messaging may be partly to blame. The failure of government to adequately monitor the COVID-19 situation and to communicate the true risks to the public played a role. The VirusWAtch surveillance system, which was established in 2007, has been partially defunded and rendered less able to respond to the SARS CoV2 pandemic. If this surveillance system was rebooted and rolled out now to all general practices, the state would have a highly effective early warning system which would renew the confidence of GPs and patients. The cost would be miniscule compared to the benefits of an accurate real-time assessment of the risk this virus actually poses. I am often asked whether WA should now re-open its borders. While it is essential to the economy
and the future of the state, my answer is still no because I don’t think we have a sufficiently robust and ethical risk-based decisionmaking process in our businesses, organisations and government bodies.
This means we are destined to repeat the mistakes of other countries, even though we have successfully bought (at great cost to our community) precious time to prepare ourselves. There is a smorgasbord of opportunities to improve our society (and at the same time mitigate the risk of SARS CoV2) that have emerged through this pandemic. The biggest risk is us not capitalising on the benefits and going back to the bad old ways of doing things. We have uncovered fantastic new ways to improve the environment through reduction in energy consumption and greenhouse gas emissions. We have increased outdoor activities, seen the benefits (for many) of working from home and recognised the importance of local supply chains. Judicious use of telephone consultations and widespread use of video conferencing to avoid unnecessary travel are all examples that will bring long-term benefits which should go a long way to solving many of the problems of the 21st century. We need a risk-based decisionmaking framework built on Respect (empathy and compassion i.e. understanding and kindness). By fully understanding the benefits we bring to each other, weighing these against the potential risks, we can restructure the way we do things to maximise benefit and minimise risk.
There is little in life worth doing that does not involve risk. Trying to avoid all risk brings the far greater risk of lost opportunity. We need to get back to football, interstate and overseas travel and the full delivery of health care services, but this will require the government to facilitate a process of sensible risk-based decision making. The architects of that model must be the people. Government officials can’t possibly understand the intricacies of every individual business and organisation in the state.
We need our community leaders to be given the freedom to work with their members to promote the benefits of what we do and to develop codes of practice (in conjunction with organisations such as WorkSafe) to help mitigate the risks of SARS CoV2.
This is impossible to achieve if we are forbidden from introducing measures to mitigate risk such as NAT testing of asymptomatic individuals. We also need enhanced surveillance systems, funded and coordinated by government (such as VirusWAtch), that will help us monitor and respond to the risks of SARS CoV2 as they evolve.
Latest guidelines for PCOS diagnosis
What is Polycystic ovarian syndrome (PCOS)? An endocrine condition primarily associated with alterations in testosterone and insulin hormones with known heterogeneous presentations involving a woman’s appearance, fertility, cardio-metabolic risk and mental health. In 2018, the first international guidelines for PCOS were published.
Diagnosis of PCOS Diagnosis has been challenging for a number of reasons. The widely accepted Rotterdam criteria holds true for diagnosis. The most important tool in diagnosis involves a detailed clinical history and examination. Biochemical and imaging tests provide supportive evidence for diagnosis. Rotterdam Criteria: 1. Oligo-ovulation or anovulation 2. Clinical or biochemical signs of hyperandrogenism 3. Polycystic appearing ovaries on ultrasound (PCOM) Any two of the above three criteria are required for diagnosis after conditions that mimic these symptoms have been excluded. Exclusion of other cause include testing for TSH, prolactin, FSH and based on clinical picture test for Cushing’s, congenital adrenal hyperplasia or neoplasia. 1. Oligo-ovulation and anovulation is defined:
First year post menarche, it is common to have irregular menstrual cycles • >1 yr post menarche > 90 days for any cycle • >1- <3 yrs post menarche cycles of <21 to >45 days • > 3 yrs post menarche, <21 or >35 days or <8 cycles a year • Primary amenorrhoea by age 15 or >3 yrs post thelarche 2. Clinical or biochemical signs of hyperandrogenism
Clinical hyperandrogenism: • Can be objectively quantified
using a modified Ferriman
Gallway score for the presence of terminal hair (not vellus).
Scores of ≥ 4-6 changed from the previous score of 8. Consider racial and ethnic variations. • Acne on its own is not a feature of hyperandrogenism, especially in the adolescent age group.
However, severe cystic acne or acne persisting well beyond adolescence with the presence of biochemical evidence of hyperandrogenism can be considered as a criterion.
Biochemical Hyperandrogenism: • Assessed by testing for testosterone and SHBG to calculate free androgen index (FAI) and/or calculated free testosterone in follicular phase. • Androstenedione and DHEAS testing can be done if testosterone levels are normal, and 17 OH progesterone testing if congenital adrenal hyperplasia is suspected. Other causes of hyperandrogenism include idiopathic hirsutism, classical and non-classical congenital adrenal hyperplasia and obesity related hyperandrogenism. Androgen secreting neoplasia should be suspected in the setting of new and rapidly developing hyperandrogenic symptoms. 3. Ultrasound – Polycystic ovarian morphology (PCOM) • Up to 70% of adolescents meet USG criteria for PCOM as multicystic ovaries are common in this age group. Hence USG should not be performed before eight years following menarche. • In adult populations, a transvaginal approach is preferred. More than 20 follicles in either ovary and/ or >10ml ovarian volume is required for the diagnosis. Caveats to consider: • When the clinical picture is unclear (specially in adolescents), it’s advisable to defer the diagnosis and reevaluate the patient in a few years. Labelling such a patient as
Main Laboratory: 310 Selby St North, Osborne Park
General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at www.clinipathpathology.com.au Dr Kalani Kahapola Arachchige Chemical Pathologist and Endocrinologist About the Author Kalani has special interests in female reproductive endocrinology. Kalani maintains an endocrinology practice at the Keogh Institute and at the WA Specialist Clinic.
“at risk of PCOS” and deferring the definitive diagnosis for up to eight years post menarche is considered reasonable. Women with PCOS, as they reach their fourth decade, can develop regular menstrual cycles and notice an improvement in the androgen levels. Similarly, persistence of hyperandrogenic features into menopause is also possible. Obesity is not part of the diagnostic criteria. It is important to understand that all obese women do not have PCOS and vice versa. Obesity is considered a different entity to PCOS and can lower SHBG and lead to increase FAI contributing menstrual irregularity. Lean women with PCOS tend to have more hyperandrogenic features whilst obese and overweight individuals are more likely to show signs of insulin resistance. Even though insulin resistance and raised LH: FSH ratio reflects the underlying pathophysiology in PCOS, these markers are not used as diagnostic criteria due to their non-specificity.
Further reading: https://www. monash.edu/__data/assets/pdf_ file/0004/1412644/PCOS_EvidenceBased-Guidelines_20181009.pdf
Consumer sentiments
The Consumers Health Forum conducted a survey which reveals some stark numbers about how patients felt about accessing their doctor during the pandemic, and perhaps some of those behaviours might be here to stay.
The results should certainly influence how health services may adapt to the changing moods. See the infograph here. Consumers were also surveyed by the Australian Digital Health Agency about what they wanted from their My Health Record and the top five on the wish list were test scans and results, notes from their GP, information on medicines they have been prescribed, Medicare information and their immunisation status – all very useful things to have at your fingertips. The ADHA responded by fast-tracking the uploading of information from the Australian Immunisation Register for those records which had not been updated. At the end of April, of the 22.75 million My Health Records nearly 70% had information in them; including nearly 10 million with immunisation information.
MHR Statistics (April 2020) • 22.75 million My Health Records • 15.6 million records with data in them • 1.95 billion documents uploaded • 65 million clinical documents uploaded – by hospitals, pathologists and radiologists • 128 million medicine documents uploaded – by GPs and pharmacies.
CONTINUITY OF CARE COLLABORATION
CONSUMER SURVEY:
ACCESS TO HEALTHCARE DURING COVID-19 During the COVID-19 pandemic, there was a significant drop in engagement with healthcare services for non-COVID health issues in Australia. In May 2020, the Continuity of Care Collaboration (CCC) 52 % conducted a survey of 729 people about access to healthcare. of respondents said they had delayed or avoided a medical appointment in the last 3 months
MOST COMMON
SERVICES MISSED 32% General Practitioner BARRIERS TO KEEPING UP WITH REGULAR HEALTH CHECKS
21%
22%
Allied Health Practitioner
Pathology Test
THE MOST COMMON FEELINGS ABOUT USING HEALTH SERVICES WERE:
59% 55%
worried they would be around people with COVID-19 if attending health appointments
felt it was safe to delay regular appointments if nothing has changed and they are feeling OK
36% 31%
were worried health services were too busy
did not feel safe visiting healthcare services in person
51%
said they would only seek medical help face to face in an emergency
43%
said they prefer to have their usual appointments over the phone or online at the moment
47% of women preferred telehealth options compared to 34% of men
36 % were worried about taking public transport to health appointments
30 % said that health services they usually use are closed
28 %
found telehealth could be difficult to use due to technology or poor access to internet / phone
23 %
were worried they could be breaking lockdown rules
Suppliers scrutinised
In the wake of the procurement scandal that rocked the NMHS, the WA government is establishing a debarment regime aimed to improve business practices and provide the Government with the power to suspend or debar suppliers from the procurement process. In the worst cases of wrongdoing, such as a supplier being convicted of fraud, bribery or corruption, the new regime would prevent these suppliers from doing business with government. Public feedback of the regime is sought by July 27.
Vax for at-risk
The meningococcal B vaccine will be funded under the National Immunisation Program for the first time this month, available now for people at highest risk from infection. From July 1, MenB-MC, sold as Bexsero, will be funded for Aboriginal and Torres Strait Islander children under two, and for people of any age with any of three immunological risk conditions: defects or deficiency in complement components; treatment with the monoclonal antibody eculizumab; or asplenia. People with those risk conditions are also eligible for the combination ACWY meningococcal vaccine under the NIP, as well as pneumococcal and Haemophilus influenzae type B vaccines.
Geraldton spend
Work is set to start on the $73.3 million redevelopment of Geraldton Health Campus. Ground works are expected to commence soon and be completed in the first quarter of 2021. The health campus will remain fully operational throughout the redevelopment, which will include an expanded emergency department and a new intensive care unit colocated with a redeveloped eightbed high dependency unit. A new integrated mental health service, with a 12-bed acute psychiatric unit and a mental health short stay unit, will also be built as part of the improvements. Building is expected to be completed by 2023. The regional city’s mental health step up/step down service, which will have 10 beds, is also one step closer with a $5.6 million injection from the WA government. Similar services are under way in Kalgoorlie and Karratha.
A dying wish...
Professor Samar Aoun from the Perron Institute and La Trobe University will conduct a review of patient perspectives of palliative care models. Previous research indicates that end-of-life experiences for many Australians does not reflect their values or choices. Many, for example, say that in the final stages of their life they want to be at home, surrounded by family and friends, but despite that preference and advances in palliative care services, fewer than 10% experience this. The independent review will look at patient experiences and preferences on receiving palliative care and the perspectives of their families and carers. It will also explore the needs
of those who were unable to access palliative care. The findings will be put to service provider forums to develop ‘enhancements’ to palliative care models in WA.
WA leads the way
BreastScreen WA has become the first breast screening service in Australia to connect to My Health Record, giving women their mammogram results as soon as their test is assessed. The service has been providing results to women electronically since last year and they can also choose to receive either an SMS or a letter, and their GP is also kept informed electronically if the patient consents.
No heroics, please
The TGA has reminded advertisers that therapeutic goods advertising must not undermine public health campaigns. The warning is aimed at advertisements for cold and flu medicines that may urge the old ‘soldier on’ concept. In the time of COVID, anyone with cold and flu symptoms (even if temporarily controlled) are urged to stay at Mental health, southside
Bethesda Health Care is spreading its wings southwards with an approved plan to build a private mental health service in Cockburn.
It was announced back in February when the world was turning on its head with coronavirus. The service on 10,000sqm of land in Cockburn Central West will include 40 overnight beds (for voluntary adult admission only), a mental health and wellbeing centre and consulting suites with construction due to begin at the end of 2020 and the doors are expected to open in 2022/23.
eScripts are coming
It looks like the practice management software companies home.
are all ready and raring to push send on eScripts with all the major companies applying for national approval. In WA, the state government has approved the use of Bp Premier Jade SP3 Build 1.10.3.894 for prescribing and Minfos software for dispensing. This was the state of play as we were going to press and that other software providers are pending.
SJGHC opens RMO applications
St John of God Health Care has opened applications for RMO positions across the organisation’s Midland, Mt Lawley, Subiaco and Murdoch hospitals.
CEO Dr Shane Kelly said that the response to COVID-19 demonstrated how essential it was that the health system was integrated. Clinical experiences included general medicine, oncology, respiratory, cardiology, emergency medicine, orthopaedics and obstetrics and all things in between. A drug developed by UWA’s ‘spinout’ company Dimerix will be used in a global trial to treat patients who have Acute Respiratory Distress Syndrome (ARDS) as a result of COVID-19. DMX-200 is a potential renal therapy to reduce damage from inflammatory cells limiting onset of fibrosis.
The Department of Health and Western Australian Health Translation Network grants program is sinking $1.1 million into projects that will increase understanding of the short- and long-term health impacts of COVID-19 as well as provide a data collection system.
Respiratory physician Dr Anna Tai at SCGH will lead a team exploring the use of convalescent plasma in early treatment of COVID-19 patients. The research will allow scientists to study the technique which has been used to treat other viruses such as Ebola and SARS.
A/Professor Roslyn Francis and her team from UWA will examine whether inflammation associated with COVID-19 persists in the lungs and blood vessels after a person has recovered from the virus.
UWA Professor Jon Watson and team will develop an integrated data and biobanking platform to record and collate clinical information on patients infected with the COVID-19 virus.
Results of UK trials (still to be peer reviewed) of a cheap and widely used steroid, dexamethasone, shows reduced death rates of about a third of critically ill COVID-19 patients. Excitement is being tempered by The Lancet‘s recent retraction of COVID studies but it hasn’t deterred Britain's Health Ministry from approving the drug’s use in the NHS.
