Tertiary eating disorder services: is it time to integrate specialty care across the life span?

Objective: Australian tertiary eating disorder services (EDS) have a divided model of care, where child and adolescent mental health services (CAMHS) support patients until the age of 18 years, and thereafter, adult mental health services (AMHS) provide care. Consumers and carers have criticised this divided model because the age boundary occurs during the peak period of onset and acuity for eating disorders. Most CAMHS patients are lost to specialty follow-up around age 18, increasing the risks of relapse and premature mortality from eating disorders, since young women (aged 15–24) have the highest hospitalisation rates from anorexia nervosa. The current article is a commentary on the transition gap and possible service designs. Conclusions: Eating disorders require access to specialty treatment across the life span. The Australian Federal Government has expanded all-age care through the 2019 Medicare Benefit Schedule (MBS) eating disorder plans. Some new MBS patients require a rapid step-up in care intensity to a tertiary EDS, thereby increasing demand on the public sector. State/Territory Governments should strengthen EDS using the ‘youth reach-down’ model, where AMHS extend EDS to age 12. Vertical service integration from 12 to 64+ facilitates continuity of care for the duration of an eating disorder.

Primary Care Provider Attitudes and Perceptions of Routine Cognitive Screening in Older Adults

The 2011 Annual Wellness Visit (AWV) Medicare benefit includes a cognitive screening component intended to improve screening of older adults. However, available literature only presents physician perspectives on cognitive screening prior to 2011. The purpose of this study was to explore primary care provider (PCP) attitudes and perceptions of cognitive screening in older adults. An Internet-based survey link was sent to Virginia professional organizations and clinics to distribute to PCPs serving older adults. Likert scale, multiple choice, and free response questions were used to understand current attitudes, perceptions, and practices. The sample (N=39) was comprised of 26 nurse practitioners (NPs), 9 physicians, and four who did not disclose role. Most participants were aware of the AWV (n=31, 88.6%) and agreed that early detection “promotes earlier diagnosis and access to resources” (mean ± standard deviation,1.58±0.69). However, less than half of NPs screened annually (n=10/26, 38.5%) and even less conducted screening during an AWV (n=7/26, 26.9%). About half of MDs conducted cognitive screening during an AWV (n=5/9, 55.6%). Although NPs screened less, they more strongly agreed that screening should occur annually (1.92±1.15 vs. 2.67±1.23) and “additional training would improve [screening] ability” (2.04±1.0 vs. 3.22±1.20). Also, few NPs independently managed impairment (n=5/26, 19.2%) compared to MDs (n=5/9, 55.6%). Our findings demonstrate that NPs screen less and feel less prepared to conduct cognitive screenings. It is important to provide additional resources and training for all PCPs, but especially NPs who are rapidly entering primary care to help improve identification and management of cognitive impairment.

Antiepileptic Drugs, Polypharmacy, and Quality of Life in People Living with Epilepsy Managed in General Practice

Objective Recently, instances of general practitioners (GPs) prescribing antiepileptic drugs (AEDs) have increased. We aimed to investigate the use of AEDs in a community sample of people with epilepsy and the effect on quality of life (QoL). Methods Responses from the Australian Epilepsy Longitudinal Study (AELS), Pharmaceutical Benefit Scheme (PBS), and Medicare Benefit Scheme (MBS) data were used. Linear regression was used to investigate the relationship between the numbers of AEDs and QoL. Results Fifty people with epilepsy were prescribed an average of two AEDs. The most common were lamotrigine, sodium valproate, and levetiracetam. Eighty-two percent were prescribed medications from two or more categories of medications. A lower QoL at wave 2 of the AELS was significantly associated with a higher number of AEDs. Conclusion Given the high number of people with epilepsy being cared for in general practice, GPs must understand the risks and benefits of epilepsy monotherapy, polytherapy, and polypharmacy.

Liability and collaborative arrangements for nurse practitioner practice in Australia

The purpose of this paper is to clarify the relationship between medical practitioners (MPs) and nurse practitioners (NPs) in general, and privately practising NPs (PPNPs) in particular, in relation to collaboration, control and supervision in Australia, as well as to explore the difficulties reported by PPNPs in establishing mandated collaborative arrangements with MPs in Australia. In order for the PPNPs to have access to the Medicare Benefit Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) in Australia, they are required, by law, to establish a collaborative arrangement with an MP or an entity that employs MPs. This paper begins by describing the history of and requirements for collaborative arrangements, then outlines the nature of successful collaboration and the reported difficulties. It goes on to address some of the commonly held misconceptions in order to allay medical concerns and enable less restrictive access to the MBS and PBS for PPNPs. This, in turn, would improve patient access to highly specialised and expert PPNP care. What is known about the topic? NPs have been part of the Australian health workforce since 1998, but until 2009 their patients did not receive any reimbursement for care delivered by PPNPs. In 2009, the Federal government introduced limited access for PPNPs to the MBS and PBS, but only if they entered into a collaborative arrangement with either an MP or an entity that employs MPs. What does this paper add? The introduction of collaborative arrangements between PPNPs and MPs seems, in some instances, to have created confusion and misunderstanding about the way in which these collaborative arrangements are to operate. This paper provides clarification of the relationship between MPs and NPs in general, and PPNPs in particular, in relation to collaboration, control and supervision. What are the implications for practitioners? A clearer understanding of these issues will hopefully enable greater collegial generosity and improve access to patient care through innovative models of service delivery using NPs and PPNPs.

Prescription Drug Coverage and Outcomes of Myeloma Therapy Among Medicare Beneficiaries

Purpose Novel parenteral (bortezomib) and oral (lenalidomide) therapies have improved survival in myeloma, but the standard Medicare benefit covers only parenteral drugs. We examined the association between prescription drug coverage, receipt of therapy, and survival among Medicare beneficiaries with myeloma. Methods Using SEER-Medicare data, we identified enrollment in a Medicare Part D plan (PDP) or other creditable prescription drug coverage (OCC) among 9,755 beneficiaries who were diagnosed with myeloma in 2006 to 2011. We examined the receipt of active myeloma therapy and that of classic cytotoxic agents or bortezomib as first-line regimen and overall survival. We report relative risk (RR) for binary outcome comparisons and 3-year restricted mean survival time (RMST) ratios, with 95% CI, adjusting for baseline patient- and disease-related characteristics. Beneficiaries with diffuse large B-cell lymphoma, a cancer that is uniformly treated with parenteral chemotherapy, served as a comparison cohort. Results Compared with beneficiaries without prescription drug coverage, PDP or OCC enrollees were more likely to receive active myeloma care, and PDP enrollees were less frequently treated with parenteral agents (adjusted RR, 0.86; 95% CI, 0.80 to 0.93) or classic cytotoxic agents in particular (RR, 0.62; 95% CI, 0.51 to 0.76). Overall survival was significantly better for beneficiaries with PDP coverage (adjusted RMST ratio, 1.16; 95% CI, 1.11 to 1.20) or OCC (RMST ratio, 1.16; 95% CI, 1.12 to 1.21). In contrast, we observed no survival differences by prescription drug coverage status in the control cohort with lymphoma. Conclusion Prescription drug coverage is associated with decreased use of classic cytotoxic chemotherapy and better survival among Medicare beneficiaries with myeloma, which suggests improved access to all existing treatment options. As oral targeted agents increasingly replace parenteral chemotherapy in oncology, adjustments in coverage policy are needed to ensure access to optimal treatment.

Utilisation of Medicare-funded schemes for people with cardiovascular disease

The aim of this study is to investigate the utilisation of Medicare Benefit Scheme items for chronic disease in the management of cardiovascular disease (CVD) in general practice and to compare characteristics of CVD patients with and without a General Practice Management Plan (GPMP). Subgroup analysis of Treatment of Cardiovascular Risk using Electronic Decision Support (TORPEDO) baseline data was collected in a cohort comprising 6123 patients with CVD. The mean age (s.d.) was 71 (±13) years, 55% were male, 64% had a recorded diagnosis of coronary heart disease, 31% also had a diagnosis of diabetes and the mean number of general practice (GP) visits (s.d.) was 11 (±9) in 12 months. A total of 1955/6123 (32%) received a GPMP in the 12 months before data extraction; 1% received a Mental Health Plan. Factors associated with greater likelihood of receiving a GPMP were: younger age, had a diagnosis of diabetes, BMI > 30kgm–2, prescription of blood pressure-lowering therapy and more than ten general practice visits. Enhancing utilisation of existing schemes could augment systematic follow up and support of patients with CVD.