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Transcript
Norman Swan: Hello, and welcome to the Health Report with me, Norman
Swan. Today, the importance of knowing how to do cardiopulmonary
resuscitation, and having someone who knows CPR near to you when you have
a cardiac arrest in the street. We'll get our teeth into misleading dental data in
Australian children. And saving bloods and saving lives and money at the same
time.

What could be more symbolic of modern medicine than the blood transfusion?
We are exhorted to donate blood to save lives, yet internationally blood is one of
the most wasted products in healthcare. In fact its use is associated with risk and
poor outcomes. A radical program called Patient Blood Management pioneered
and researched in Western Australia has shown spectacular results and is now
being adopted internationally. Using less blood has resulted in fewer deaths and
significant financial savings. In our Perth studio is Gary Geelhoed, Chief Medical
Officer of Western Australia, and on the line that Simon Towler, a former Chief
Medical Officer of WA, who is involved with blood management reform at a
national level in Australia. Welcome to you both to the Health Report.

Simon, you were here from the beginning. We'll get to Gary in a moment. How
did WA get to be the international leader in blood management?

Simon Towler: Look, Norman, there's been programs in Western Australia

dating back for a long time, and in fact some of the early programs started in
small hospitals, particularly focusing on providing the opportunity for blood-free
surgery for Jehovah's Witnesses. But what became clear was that patients
managed through those programs were doing well, and in fact internationally it
became increasingly clear that the evidence suggesting there was, shall we say,
the possibility of harm with transfused blood products was growing substantially.

Norman Swan: What sort of harm?

Simon Towler: The things that we know are almost certain is that as you
increase the amount of transfused product administered, the risk of infection
increases in most clinical settings. There's quite a lot of evidence now
accumulated suggesting that transfusion alters the immune system and can
change outcomes, such that there is certainly suggestive evidence that
transfusion at the time of surgery for cancer may be associated with higher rates
of recurrence. And so this evidence has been growing over time, balanced by a
lack of real evidence of quality benefit from getting transfused, and certainly
when you transfuse above what are recommended levels. So those things taken
together suggested that quality practice in transfusion in the care of patients was
something that was well worth focusing on. When I became the Chief Medical
Officer in Western Australia we thought this was a good place to start. And
worldwide this has now been strongly taken up.

Norman Swan: And we'll come back to that later. And just before I get to Gary
Geelhoed, Simon, when you started this study in 2008, Western Australia was
already a low user of blood. I mean, there's important context when you hear the
spectacular results, as we will from Gary in a moment. You were already
internationally a low user of blood products.

Simon Towler: Yes, we were, but I think because there had been programs in
Western Australia and we had been looking at what was possible, and also we
had been looking at what was going on in individual hospitals across the world,
we recognised that we could improve further, and I'm sure Gary will outline what
has been achieved. But the focus is very much on the patient, not just on the
transfusion. We believe that patient blood management is a descriptor of quality
clinical care, not a particular focus on transfusion practices itself.

Norman Swan: So Gary Geelhoed, tell us about the…there's three pillars of this,
it's not simply teaching surgeons to do better surgery or to do more blood free
surgery, there's a whole…you call it three pillars of the blood management
system in WA, just briefly describe them.

Gary Geelhoed: Thanks Norman. Essentially a simple way to think about this,
because most blood products are actually given electively, that is for elective
surgery rather than in emergency situations. So you do have a chance to change
these things. And so the simplest way to think about it is first of all optimising red
cell mass, the second pillar is minimising blood loss, and the third one is harness
and optimise physiological reserve. The easiest way to think about that is
preoperatively. When patients came in the past, perhaps we didn't take quite so
much care if they were found to be anaemic, or we might just transfuse them
then, and then take them to theatre. During theatre, again, people would maybe
not take as much care about blood loss et cetera as maybe they had, and also
after.

So you put those things together, both preoperatively in our patients, you would
try and make sure they were much more fitter, they had a higher haemoglobin or
iron, red blood cell mass in their bodies before they went to theatre, so much less
likely to need to be transfused. If during theatre you actually used techniques so
you minimise blood loss and in some cases where it was appropriate actually
recycled blood that you were using during the surgery and using appropriate
anticoagulants and so on or at least the opposite of that, and also post
operatively taking all care, what you find is your need to actually give blood, for
the reasons Simon said, it can be life saving but in most cases you should try
and avoid blood products as much as you can, that leads to better outcomes.

Norman Swan: And you weren't so religious about saying that a certain level of
haemoglobin you need to have a transfusion, it depends on the person's physical
state as to whether they need it.

Gary Geelhoed: Very much so, it was all about horses for courses, and so we
weren't too prescriptive there because, as you can imagine, people's pre-existing
conditions or the reasons why they were getting or might need a blood
transfusion would vary greatly. So to some extent it was really raising people's
awareness to say, look, think of it in every case. Do you need to definitely
transfuse this person, and if so, do they need more than one unit of blood? So,
for instance, it used to be that only about a third of cases got only one unit of
blood, and with our program that's virtually double, so the two-thirds would only
get one unit of blood. Because the negative things that Simon was talking about,
a lot of it is dose-related.

Norman Swan: And surgeons taught other surgeons blood-free techniques, or

blood loss techniques.

Gary Geelhoed: That's right, there was a whole suite of things that were
introduced. So this is people seeing the patients before theatre, the people who
dealt with the patients during theatre and after theatre. A lot of it was actually in
this modern day and age actually getting the data and feeding that back to the
surgeon, showing them what their blood usage was compared to their peers and
other departments and other hospitals. So that's a positive way of getting people
to change their behaviour.

Norman Swan: So you've just published your findings, you and Simon are on the
paper. What were the headline findings from a six-year study of this program?

Gary Geelhoed: In some ways the point about this was taking the evidence that
was available and then applying it system-wide across Western Australia. Many
people would be appalled to find that many times with research findings it takes
anywhere between 5 to 12 or more years to get it into practice. This was an
attempt to system-wide change things because we had the evidence to show that
a lot of this time the blood wasn't needed and in fact was bad for patients. So first
of all it was just looking at the units of blood or blood products that were being
used per admission, and that dropped 41% during the five or six years that the
study was on.

Norman Swan: And then this enormous saving of money, between $80 million
and $100 million, not just in blood products but in the consequences of all the
savings, you've got lower death rates, lower numbers of heart attacks and
strokes.

Gary Geelhoed: Exactly, and so it was a win-win situation where you're getting
better health outcomes and you're saving money. And as you say, many of those
things where, as Simon said, the evidence was emerging, that perhaps giving
blood unnecessarily was causing these things. So, as you say, the things that
dropped, hospital mortality dropped actually, length of stay in hospital, hospital
acquired infections dropped, associated heart attacks and stroke for patients who
had the blood products and had the surgery. All these things moved in a very
positive direction, and you can see obviously how you are going to save a lot of
money too, once those things start coming down.

Norman Swan: So Simon Towler, just briefly, I take it this has been taken up
with alacrity not in Australia. It has been taken up internationally, I think the
European community has now adopted the WA system, has the rest of Australia?
You sit on the national committee.

Simon Towler: So the uptake has been variable. There is now a collaborative
that has been performed with the Australian Commission for Safety and Quality
in Healthcare, taking a group of leading hospitals and looking at what works
within the institutions. But I go back to one of the key recommendations that
came out of patient blood management was that health services establish a
multidisciplinary, multimodal, perioperative blood management program. In other
words, a team of people with expertise in the different elements of care working
on and putting in place reliable programs in the hospital to ensure these things
are actually implemented.

I think the disappointing thing is that despite this being a central recommendation
and there being significant changes in clinical practice at the individual level for
the very reasons that Gary has talked about, the widespread application of a
program approach, in my view, has still not progressed as much as would be
best and would lead to the best possible outcomes. And I think the recent paper
confirming that reduced complications and reduced health costs should give
greater import to those people in decision making decisions to adopt a PBM
approach on a systematic basis.

Norman Swan: Thank you very much to you both. That was Simon Towler,
former CMO of Western Australia, Chief Medical Officer. He's gone back to his
work as an intensive care specialist, amongst other things. And Gary Geelhoed,
who is the current Chief Medical Officer of Western Australia. Congratulations.
And thanks to you both.

You're listening to the Health Report here on RN, ABC news and CBC radio
across Canada.

A Danish study in this week's New England Journal of Medicine reinforces the
recommendation that all of us should know basic cardiopulmonary resuscitation
for that moment when someone has a cardiac arrest in front of us. A one-year
follow-up of the outcomes of out-of-hospital cardiac arrest and whether there was
a bystander to perform CPR or grab a public defibrillator has shown significant
benefits. The lead author is Kristian Kragholm who is at Aalborg University
Hospital in Denmark. Thanks for sparing Australia your time, Dr Kragholm.

Kristian Kragholm: Thank you, and thank you for inviting me.

Norman Swan: So briefly, the study, what did you do?

Kristian Kragholm: So, briefly what we did was we used data from the Danish
cardiac arrest registry, which is a nationwide registry containing information on all
cardiac arrests in Denmark that occurred since June 2001. And what we did was
we linked this cardiac arrest information, including information on whether
laypersons or EMS personnel witnessed the arrests, whether it was unwitnessed,
whether bystanders stepped in and started CPR, and also whether bystanders
used an AED to defibrillate the patient. So we took this information and we linked
it to other nationwide registries in Denmark using…we have a unique social
security number that we use in all healthcare and social contexts. And so we
used this unique social identifier to link to other nationwide registries, other
hospital record registries, and also registries on nursing home admission and
other social care needs.

Norman Swan: And I'll just say in passing, Kristian, before we go on, that this
linkage of registers and availability of registers can only be dreamed about in
Australia with our anxiety about privacy which would not allow this kind of data
analysis that you've been able to do. So what did you find in relation to bystander
CPR?

Kristian Kragholm: So what we found was that in addition to increasing patient

survival and lowering mortality, we also found a significantly lower risk of nursing
home admission and brain damage following out-of-hospital cardiac arrest. So
not only can bystanders increase a person's chance of survival if they start CPR
and/or if they use a public AED, they can also significantly lower that person's
risk of surviving with disabilities.

Norman Swan: And have you got particularly high rates of bystander CPR in
Denmark compared to other countries? I mean, I notice that it went up during this
period of this study from 60% to 80%. In other words, there was a lot of
bystander CPR going on in Denmark, clearly.

Kristian Kragholm: Yes. So what we found during the course of our Danish
cardiac arrest registry time was really remarkable. We found that in the beginning
in 2001, only around 20% of all Danes started CPR when there was a cardiac
arrest. And now we have rates up to 65%. And in this study where we study 30-
day survivors, obviously the CPR rates are higher because CPR is associated
with higher chances of survival. But still, among survivors we saw a significant
increase from around 60%, 65%, to more than 80% during the time on the study
period we had.

Norman Swan: And what proportion of people were actually using the publicly
available defibrillators, which are still not that common in Australia, versus
jumping on the chest and doing the high rates of chest compression?

Kristian Kragholm: Yes, and that's also another significant story of our
manuscript here because what we saw was that in the beginning hardly anyone
used a public defibrillator, simply because they weren't available, they weren't
accessible. But during the course of our study we also saw significant increase in
public defibrillation from around 1% or 2% up to 15% among survivors, and an
increase among all cardiac arrest patients from around…or less than 1% to
around 4%.

Norman Swan: So your message is learn CPR.

Kristian Kragholm: Yes, so the message is learn CPR but also use a public
AED if accessible, if available, and the message is not only to the public but it's
also to policymakers to find ways how to make a defibrillator accessible to the
public.

Norman Swan: Thank you very much indeed for joining us. Kristian Kragholm is
in the departments of anaesthesia and intensive care at Aalborg University
Hospital in Denmark. And if you're wondering what the current thing on CPR is,
it's 120 firm compressions on the centre of the chest, a minute, and you don't
necessarily have to do mouth-to-mouth anymore, but if you were you do 30 fast
compressions to 2, but make sure somebody is calling for an ambulance at the
same time. Thanks for that, an important story.

We typically think about diseases in isolation as distinct entities. But a new model
of health wants us to consider the interaction of different diseases, along with
environmental and social factors. This is the syndemics model of health. Merrill
Singer is a medical anthropologist and professor of anthropology at the
University of Connecticut who recently wrote about syndemics for the Lancet.
Welcome to the Health Report, Professor Singer.

Merrill Singer: Thank you.

Norman Swan: So, syndemic, what is…you just better take us back to
Syndemics 101. What are they?

Merrill Singer: Syndemic, the term refers to a situation where someone,

especially at the population level where there are multiple diseases in a
population, and within individuals those diseases interact with each other in
adverse ways. In other words, one disease causes another to either spread more
quickly or to cause more damage or they both impact each other. And usually
this occurs under social conditions of poverty or other marginal conditions that
make people vulnerable or cause disease to be concentrated in a particularly at-
risk population. So it's really what we refer to as a bio-social situation, because
there is interaction at the biological level between diseases, and interaction
between disease and social conditions.

Norman Swan: So what you're trying to do is force a way of thinking which takes
all factors into account, not just the disease itself as a single entity.

Merrill Singer: Well, we are trying to call attention to the fact that diseases often
do not occur in isolation, that people who suffer from one condition, that condition
may be interacting with other diseases and that's what often makes things worse.
And there are many examples of this.

Norman Swan: So why don't you give us an example which you think typifies a
syndemic.

Merrill Singer: A good contemporary example is the interaction between HIV

and tuberculosis. When those two infectious diseases are present in the body,
both those conditions are made worse by the presence of the other. So people
deteriorate more quickly if both diseases are present. There are pathways of
interaction within the body, and that interaction does indeed tend to be most
frequent in marginalised or oppressed populations, the poor et cetera, and it's
one of the contemporary syndemics that has raged in recent times.

Norman Swan: And what about obesity?

Merrill Singer: Obesity is a factor in a number of different syndemics, one of

them recently was described in a study in Puerto Rico by Professor Shir Lerman
who looked at obesity, diabetes and depression as interacting conditions that
tend to make each other worse.

Norman Swan: And moving to the developed world, to countries like the United
States and Australia? What would you say in the United States context (I don't
expect you to know about Australia) would be the most significant syndemic in
the United States at the moment?

Merrill Singer: At the moment, and it's a somewhat unusual syndemic from the
way I just described it, it's the interaction among tickborne diseases like Lyme
and other tickborne diseases. Right now tickborne diseases are the most
significant vectorborne disease in the United States. There are multiple different
diseases that are spreading to new areas, probably impacted by climate change,
it's making new habitats more available to vectors like ticks. And so we see
people coming down not with one tickborne infection but with multiple infections.
And in some cases they get sicker faster because of the interaction among
those.

Norman Swan: So I suppose I'm kind of surprised at you saying this because…I
understand the concept here holistically, but I would have thought that heart
disease, which kills more Americans than almost anything else, kills more
Australians, would be the one that you would choose. Isn't heart disease the
classic syndemic, or have I missed the point here?

Merrill Singer: I would say heart disease is in itself the most significant individual
cause of death, but it isn't always because of syndemic interaction. In and of itself
heart disease is quite capable of killing people, but certainly it does interact with
other diseases. It hasn't been well studied as a syndemic, but it's an area, like
many syndemics, that have not been examined closely in terms of how actual
conditions are interacting. Some of the diseases that heart disease interact with
are really not independent of heart disease, they are part of the same set of
conditions. So when we talk about syndemics we're talking about conditions that
exist on their own and, in some individuals, are copresent and interactive.

Norman Swan: So let's go to HIV and tuberculosis, which is an enormous

problem, particularly in South Africa but in other places as well. How does
redefining that complex of problems help deal with it?
Merrill Singer: Well, I think in that case that redefinition has occurred. That is,
people now fully recognise how damaging that interaction is and have made that
the focus of intervention, which is that you can't just treat one or the other, you
can't define one as the dominant disease, which is typically how things occurred
in the past. You might recognise that there were multiple diseases present, but
the prime one is the important one to address. With HIV and TB, people know
that you have to address both of those conditions because they both individually
are quite capable of being lethal. So that approach is already fully in place, and
it's from that example that we need to learn that we need to think about not just
how you treat two diseases but do the two treatments negatively interact with
each other, which happens sometimes when you give people multiple medicines.
And you need to think about the social conditions that promote the concentration
of those conditions in particular populations.

Norman Swan: One of your colleagues at the University of Connecticut has

written about the refugee crisis, particularly in Europe, and human rights, and
how that comes together in a syndemic. Could you just talk a little bit about
where human rights fits into this complex of disease on disease on social
conditions, economics, education and so on, and indeed human rights?

Merrill Singer: Well, it has to do with the social conditions that promote disease
concentrations. When populations are denied the right to healthcare, the right to
clean water, the right to reliable access to food, they are going to suffer from
health consequences, and it's those conditions that promote the occurrence of
syndemics. So a rights framework at least provides a legal way to talk about one
of the ways to address the upstream causes of syndemics.

Norman Swan: Dr Singer, thank you very much indeed for joining us.

Merrill Singer: Thank you for having me on.

Norman Swan: Professor Merrill Singer is a professor of anthropology at the

University of Connecticut.

Now, from time to time we at the Health Report wake up to the fact that the
mouth is part of the body, not to mention the teeth. The Australian Institute of
Health and Welfare has recently released data on the oral health of Australian
children, which both the report and a researcher in the field reckons contradicts
previous surveys. Professor Mark Tennant is the director and founder of the
International Research Collaborative on Oral Health and Equity at the University
of Western Australia. Welcome to the Health Report, Mark.

Mark Tennant: G'day Norman, nice to hear from you.

Norman Swan: So what's the problem?

Mark Tennant: Well Norman, it's interesting, if we go back in time, dental decay
in children was a condition that every kid, you and I of our generation as kids,
every kid had some sort of decay problem. And over the last 30 years, through all
sorts of mechanisms, that's diminished. And what's happened is around the year
2000…all this time we have had annual or nearly annual reports on the dental
health of children. And in around the year 2000, as the effects of fluoride and
toothpaste and general hygiene really reduced decay rates, we saw that the data
started to become more irregular in the reporting, and in fact there were hints of a
trend upward, which was discussed for a long while.

Norman Swan: Things were getting worse, according to the data.

Mark Tennant: Yes, getting worse, more decay in children since the year 2000.
And there were all sorts of discussions as to be reasons why and things. And just
last year, just before Christmas, the group who has been collecting this data for
the AIHW over the last 25 years or so, they released a book. And towards the
back of the book it seems that they have pointed out that this new data that they
have collected on a much more stable scientific sampling basis has found the
decay rates are actually much lower than the previous reports were starting to
raise. In fact, half for 12-year-olds, which is the usual age we measure decay in.

Norman Swan: So in other words they were 50% lower than you would have
otherwise thought?

Mark Tennant: Yes.

Norman Swan: So which is accurate, the new one or the old one?

Mark Tennant: It's interesting you ask that, I think the new one is done on a
much more structured sampling basis.
Norman Swan: So it's good news, Australian children have better dental health
than we previously thought. Let's assume that that's the standard, we could get
into an endless statistical argument here…so that assumes that…some people
are saying, well, fluoride doesn't work, but this assumes fluoride does work, it
helps that argument.

Mark Tennant: This does show we have really good oral health in this country
for children. In fact between 60% and 70% of children are not affected by decay
at all up to the age of 12. The issue now is that decay is clustered in small groups
of the population. And we are talking the groups of marginalised people in
poverty, Aboriginal and Torres Strait Islander people. In fact, this report shows
something in the range of four times the rates of decay of the rest of the
population are in Aboriginal and Torres Strait Islander children. So what this new
data shows us is instead of having universal services we should be highly
targeted to particular risk groups now.

Norman Swan: There is very scarce resources going into dental health for
children, and what you're saying here is focus on where the problem really is.

Mark Tennant: Yes. You know, there has been discussion about proportionate
universalism, which for your listeners means have universal coverage but do a
little bit of focus on those more at risk…

Norman Swan: So are Aboriginal children living in un-fluoridated areas?

Mark Tennant: Interesting question Norman, it's a little bit more complicated than
that. It's actually not about purely the fluoride in water. If you look across the
world, the effects in reduction of decay in children is not always tied to water
fluoridation. It's probably related to all sorts of things, including toothpaste and
brushing. So there is a lot more to the story than just water.

Norman Swan: And the solution if you intervene…we haven't got much time
left…but if you've got money to intervene, what would you do with disadvantaged
groups who are disproportionately affected by dental decay?

Mark Tennant: I would be getting highly targeted preventative services out there,
brushing programs in schools, they've been shown across the world to be
effective. I'd be moving to having services near those people in need.
Norman Swan: So this is like fissure sealing and application of fluoride in remote
dental chairs, things like that?

Mark Tennant: Yes, and actually removing dental decay, some fillings and things
as well, let's clean up decay. Just to give you an idea, about the poorest 20% of
our population has somewhere like 30 times the rates of facial cellulitis from
dental disease. This is a disease that's now focused its issues and problem in the
poor and marginalised of our society.

Norman Swan: Mark Tennant, thanks for joining us.

Mark Tennant: A pleasure.

Norman Swan: Professor Mark Tennant is the director and founder of the
International Research Collaborative on Oral Health and Equity at the University
of Western Australia.

I'm Norman Swan, this has been the Health Report, see you next