Health expenditure continues to grow
HEALTH expenditure in Australia in 2013‒2014 grew relatively slowly to an estimated total of $154.6 billion, up 3.1% on 2012‒2013 in real terms (after adjusting for inflation), according to a report released last week by the Australian Institute of Health and Welfare. The report said an estimated $6639 was spent on health per person in 2013–2014, up by $94 on the previous year — a 1.4% growth rate, which was less than half the 3.3% average annual growth over the past decade. Health represented 9.8% of Australia’s gross domestic product (GDP) in 2013‒2014, a 0.1% rise from 2012‒2013. Government revenue totalled $104.8 billion (67.8% of total health expenditure) but the federal government’s share of total health expenditure declined from 43.8% in 2008‒2009 to 41.2% in 2013‒2014. State, territory and local government share of expenditure has been around 26.6% since 2009‒2010, the report said. In the past decade out-of-pocket payments by individuals was the fastest growing area of non-government spending on health, growing to an average of 6.2% a year. The proportion of total health funding from private health insurance funds had declined steadily since 2003‒2004 from 8.1% to 7.4% in 2011‒2012, before rising to 8.3% in 2013‒2014, when the changes to income testing for the government’s private health insurance premium rebates were introduced, reducing the government’s contribution. When compared with taxation revenue, government health spending represented the same proportion of taxation revenue (24.7%) as the previous year, the report said.
Interventions work at suicide hotspots
INTERVENTIONS at locations frequently used by people attempting suicide appear to be effective in reducing suicides, according to a meta-analysis published in The Lancet Psychiatry. The authors reviewed 23 articles representing 18 unique studies on interventions at suicide hotspots. The interventions were delivered in combinations or in isolation, and classified into four general approaches — restricting access to means, encouraging help-seeking, increasing the likelihood of intervention by a third party, and encouraging responsible media reporting of suicide. One hotspot in Sydney, Gap Park, had used several interventions simultaneously by building an inwardly curved fence along the cliff’s edge, installing telephones that linked to Lifeline, and putting up signs that displayed positive messages. The study found that, in total, 863 deaths by suicide occurred over 149·85 study-years before the interventions were introduced (unweighted mean of 5.8 suicides per year) and 211 deaths by suicide over 88·0 study-years after the interventions (unweighted mean of 2.4 suicides per year). “Offered together, these interventions have the potential to complement each other”, the authors wrote. “Restricting access to means, for example, is thought to work because it can delay the suicide attempt, allowing the individual to reconsider their actions, and giving others the opportunity to intervene. Strategies that actively encourage help-seeking or increase the likelihood of intervention by a third party might therefore enable means restriction to work.” They said priority should be given to the ongoing implementation and evaluation of initiatives at suicide hotspots, “not only because of their self-perpetuating nature as places where people can attempt suicide, but also because of the effect that suicides at these sites have for those who work at them, live near them, or frequent them for other reasons”. An accompanying commentary said: “Blocking access to a hotspot can serve as an expression of important values, if done in a way that builds community awareness and support for broader efforts to prevent suicide, attempted suicide, and antecedent risks.”
Haemoglobin decline in pregnancy linked to CVD death
RESEARCHERS have identified haemoglobin decline during pregnancy as a new predictor of cardiovascular disease (CVD) death, saying early onset pre-eclampsia, pre-existing hypertension and the presence of glycosuria are the strongest predictors. The findings, published in Circulation, were based on the data from 14 062 pregnant women enrolled in the US Public Health Institute’s Child Health and Development Studies from 1959 to 1967. Deaths from CVD were linked through a national death index. The women had a median age of 26 years at enrolment and 66 years in 2011. By 2011, 368 women had died from CVD. The authors found that pre-existing hypertension, glycosuria, late onset pre-eclampsia and haemoglobin decline over the 2nd and 3rd trimesters of pregnancy predicted later CVD death. Delivery of small-for-gestational age or preterm infants, and pre-eclampsia onset before week 34 of pregnancy, significantly predicted premature CVD death. The impact of early onset pre-eclampsia appeared relatively swiftly, and was associated with very high CVD mortality by age 60 years. Women who had a preterm birth combined with haemorrhage, gestational hypertension or pre-existing hypertension had a four- to sevenfold increased risk of CVD death. Pre-eclampsia in combination with pre-existing hypertension resulted in a nearly sixfold risk, compared with a fourfold risk for pre-existing hypertension alone. The authors wrote that future research should investigate the underlying pathways that linked pregnancy complications to CVD, which might provide clues about new biomarkers in early pregnancy. In the meantime, “physicians should provide early, prompt surveillance and intervention for women with these high-risk pregnancy complications”, the authors wrote.
Atrial fibrillation increases dementia risk
ATRIAL fibrillation (AF) is associated with an increased risk of dementia, especially among younger patients, a study published in JAMA Neurology has found. The researchers analysed data on 6514 Dutch adults without dementia to assess the relationship between AF and dementia from 1989 to 2010. Participants were aged 55 years or older at baseline, and were tested for each condition during follow-up examinations every 3‒4 years. At baseline, 4.9% of the participants had prevalent AF, and during 81 483 person-years of follow up, 15.3% developed incident dementia. Among the 6196 without prevalent AF during 79 003 person-years of follow-up, 11.7% developed incident AF and 15.0% developed incident dementia. Incident AF was associated with an increased risk of dementia in participants younger than 67 years, the authors wrote. The risk of dementia was also strongly associated with duration of exposure to AF in younger participants, but not in the older participants. The authors found this association was similar for Alzheimer disease, and was independent of stroke. Several potential mechanisms underlying the association were identified, including cerebral hypoperfusion among patients with AF, which lowered cardiac output and could damage nerve cells. The authors said their results had important clinical implications because “the risk for dementia could potentially be reduced by optimal treatment of AF”. Additional studies were needed to investigate whether optimal treatment of AF could prevent or delay the onset of dementia.
Call to review miscarriage diagnosis guidelines 
CURRENT UK guidelines for diagnosis of miscarriage may be associated with misdiagnoses and should be reviewed to reflect new evidence, according to research published in The BMJ. The research, conducted across seven UK hospital units from 2011 to 2013, included 2845 women in the early stages of pregnancy who attended hospital due to vaginal bleeding, pain or hyperemesis, or for reassurance after a previous miscarriage or ectopic pregnancy. Participants had transvaginal ultrasonography confirmation of a singleton intrauterine pregnancy of uncertain viability. In three hospitals, this was initially defined as an empty gestational sac of <20 mm diameter with or without a visible yolk sac but no embryo, or an embryo with crown-rump length (CRL) of <6 mm with no heartbeat. Following guidelines amendments in 2011, this definition was changed to a gestational sac of <25 mm or embryo CRL <7 mm, with a repeat scan 1‒2 weeks later. The authors measured the mean gestational sac diameter (MSD), CRL and presence of embryo heart activity at initial and repeat transvaginal ultrasonography 7–14 days later. The final outcome was the viability of each pregnancy at 11–14 weeks’ gestation. The authors found that previous cut-off values for MSD of ≥16 mm and ≥20 mm were not clinically safe and were associated with possible false-positive diagnoses of miscarriage. The new cut-off values for MSD and CRL to diagnose miscarriage were associated with 100% specificity. However, the authors wrote that guidance relating to time between scans and expected findings on repeat scans were still too liberal. “Our data suggest that although gestational age is a factor when interpreting ultrasound findings, even with certain menstrual dates, viable pregnancies occur with small gestational sacs and small embryos at relatively late gestations”, they wrote. Protocols for miscarriage diagnosis should be reviewed to account for their evidence to avoid misdiagnosis and the risk of terminating viable pregnancies, they wrote, recommending a repeat scan 7‒14 days after the initial scan, depending on MSD, CRL and the presence or absence of a heartbeat. An accompanying editorial said that the research was an important advance that provided greater certainty for miscarriage diagnosis. However, despite ultrasound technology, “we cannot get around the fact that often we still must resort to watching and waiting”.
Asthma hospitalisations increase with smoke exposure
CHILDREN with asthma who are exposed to second-hand smoke (SHS) are nearly twice as likely to be hospitalised with asthma exacerbation, and more likely to have lower pulmonary function, according to a systematic review, published in the Annals of Asthma Allergy and Immunology. The research included 25 observational studies with a total of 434 737 children from several countries. The mean age of participants was 7.6 years and 61.4% were male. Most of the studies (96%) investigated smoking exposure at home or by parents, and 8% examined exposure outside the home. Only seven studies reported testing for SHS, whereas others relied on parent or caregiver-reported exposure. The authors found that children with asthma exposed to SHS were twice as likely to be admitted to hospital as children with asthma who were not exposed to SHS. Smoking exposure also was significantly associated with emergency department or urgent care visits and wheeze. The authors did not find a statistically significant difference in frequency of asthma exacerbation. With pulmonary function testing, the forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio was significantly lower in children with SHS exposure, but there was no significant difference in FEV1 percentage. The authors said the twofold higher risk for hospitalisation among children with asthma exposed to SHS was clinically important, because hospitalisation for asthma increased the likelihood of fatal asthma and poorer asthma control. The findings also highlighted the increased burden of disease on the health care system. The authors said that assessment of SHS should be an integral part of asthma care in children, and that future research should focus on the severity and health care cost in these children after SHS exposure stopped.

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