The after-hours GP service is in the spotlight because of a so-called cost blowout, but is it preferable to ending up in the emergency department? And, how female athletes should eat to get the most out of their training. We also look at the impact midwifery continuity of care has had in Alice Springs.

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Producer/Presenter: Ellen Leabeater

Speakers:
Margaret Faux – CEO of Synapse Medical Services & PhD student at UTS
Stacy T Sims – Senior Research Fellow University of Waikato
Bernadette Lack – Registered midwife

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Ellen Leabeater: Hi, Welcome to the show, Ellen Leabeater with you. Today, how females can get the most out of their fitness with nutrition.

Stacy T Sims: You get a really good picture of what’s happening to the woman’s physiology and then how do you apply that when they’re actually in physical activity or training states and how do we manipulate nutrition and training around what’s happening.

Ellen Leabeater: And, how midwifery continuity of care is making a difference in Australia’s red centre.

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Ellen Leabeater: But first on the show, you’ve probably heard a lot about Medicare this election cycle this election cycle, and you may have recently heard about the so-called “blow out” of after-hours GP services. The after-hour GP service is a bulk-billed service that costs four times as much as a standard GP consultation, and it cost Medicare $195 million in the last financial year. The theory is that it keeps people out of the emergency room, but is this the case? Margaret Faux is the CEO of the largest medical billing company in Australia. She’s also currently undertaking a PhD on Medicare claiming and compliance at the University of Technology Sydney.

Margaret Faux: So after-hours care as defined in the Medicare benefits schedule… well there’s two different categories. There’s after-hours, which is after 6pm from memory and then there’s unsociable after-hours, and that’s between 11pm and 7am. So there’s different categories depending on whether it’s just after-hours or unsociable after-hours.

Ellen Leabeater: And then this is broken down into urgent and non-urgent?

Margaret Faux: Yeah, that’s right. So the urgent after-hours items pay about $130, something like that, $130 to $150. And the non-urgent ones pay about half that. But they both… they all pay more than the daytime consultation services that GPs can claim.

Ellen Leabeater: Which is $37.05.

Margaret Faux: Well that’s the standard one, that’s the Item 23 that everybody knows. So yeah, that’s $37.05 and that will be frozen for the foreseeable future.

Ellen Leabeater: So, what sort of people are getting urgent after-hours service.

Margaret Faux: Well that’s a good question Ellen. I don’t have access to that information. I don’t know the breakdown of the demographic of who’s actually utilising that service. But it was interesting to see a service actually embark on a TV advertising campaign recently. That’s the first time in all the decades I’ve been working in this area that I’ve ever seen that.

Ellen Leabeater: So there was an ad campaign promoting the after-hours service?

Margaret Faux: Yeah, yeah. And I think one of the features of after-hours services is that traditionally, Australians didn’t really know how to access after-hours care, so what they would do is ring their GP or they would go to an emergency department. And GPs, to be accredited have to have after-hours arrangements and they use deputising services and various other services to meet those requirements. And so if you called your GP, there would be a message there advising you where to go, and that might be a deputised service that would help you after hours.

Ellen Leabeater: What do you mean by deputising service?

Margaret Faux: Well, it’s like the GP outsourcing to another service to say you provide our after-hours care. But those services do also have to meet certain standards and be accredited. You can’t just put your hand up and say, you know, I’m going to be an outsourced, out of hours GP deputising services. So there are rigid standards that they all have to adhere to.

Ellen Leabeater: What can the after-hours GP offer you as a patient?

Margaret Faux: Well that is a great question because I think they can only do three things if you think about it. They can write a prescription; they can administer drugs – the drugs that they’ve got in their bag; or they can tell you to go to an emergency department or see the GP in the morning. So, I don’t think there’s much else that they can do. It’s three things: prescribe; administer drugs; or say go to the doctor or go to the emergency department. All they’ve got is a stethoscope and their doctor’s bag. That’s my understanding; I mean I stand to be corrected on that. If there are really sophisticated after-hours providers that are walking around with small ultra-sound machines like that, and they do exist – obstetricians and gynaecologists quite often have these little mobile ultra-sound machines. I think that’s unlikely. And therefore you’ve got to be thinking about things like, if all their doing is writing a prescription, and you can’t get the prescription… you can’t collect it until the next day anyway, was that an appropriate spending of tax-payer’s money? If they’re just saying go to an emergency department, perhaps you should have gone there anyway. But perhaps there is a valid argument for administering acute pain relief. That might appropriate, I can certainly see a need for that.

Ellen Leabeater: In my mind, that is exactly what I the after-hours GP… I feel like the after-hours GP is keeping patients out of the emergency department, but you’re saying otherwise.

Margaret Faux: Well, again, there have been some studies in this area. And on my reading of those studies, there is no hard evidence at the moment that GP after-hours services actually reduces the incidence of presentations to emergency departments, in fact there was one study that was published in the Medical Journal of Australia in 2009, so it’s a little while ago now, but it actually went to great lengths to dispel the myth that general practice after-hours services reduces presentations to emergency departments, so that study came to the conclusion that it didn’t. But I think that’s probably what we need at the moment – to have a discussion about this. What we probably need is some up to date evidence on how many of these patients who are using these services would have gone to an emergency department.

Ellen Leabeater: There’s another issue in information exchange.

Margaret Faux: Absolutely –

Ellen Leabeater: So, you know, if your family GP is outsourced, is that information getting back to your GP the next day.

Margaret Faux: Yeah, so that’s a really important issue, which is continuity of care. So, your GPtypically will know a great deal about you and your health and the health of your family and will have been through that journey with you, so if a deputised doctor – an out of hours doctor who doesn’t know you – comes out to see you, they obviously will not have access to all of that information. And there was a study that demonstrated that after-hours doctors tended to use more expensive medication, and I think there was an increased use of morphine too, and that may not necessarily be a bad thing, but because they don’t know you, they have to do something immediate and treat you the best that they can. And there can be no question that these are anything other than appropriately skilled and trained doctors that do have your best interests at the centre of everything that they do. That’s not the issue. But then the other issue is: how do they communicate what they’ve done back to your GP the next day. So how does the GP know what happened to you overnight? That is a really valid issue that I think needs to be the subject of a study if it hasn’t already been.

Ellen Leabeater: There’s also concern that there has been an increase in people using this service. I think $195 million dollars has been spent on the urgent after-hours care. Do we know why there is this increase?

Margaret Faux: Well, I think we will continue to see an increase now that the Medicare rebate has been frozen. I mean, doctors are only human and I just think people sometimes forget that. They’re only human and they will protect their livelihoods. So whilst it’s getting harder and harder and harder for GP practices to remain viable, they will look to other models of operating. And I think you’ll see the rise of entrepreneurial GPs. And this is available in the Medicare benefits schedule. They’re not doing anything untoward in relation to claiming under the schedule. It’s there. And so, it’s a fee for service scheme, and I know that’s simplistic to say it, but where there’s a fee, there’ll be a service, and where there’s a higher fee, there’ll be more service, so, these fees are higher, it’s harder to maintain a viable general practice, so I think you’ll see quite a lot of this. I think it’ll continue to increase. And I also think you’ll see GPs closing there small practices and joining larger corporate organisations where they can share infrastructure costs and then you will get an increase in the corporatisation of general practice as well.

Ellen Leabeater: So if more doctors are offering this after-hours service, why are more patients flocking to it then?

Margaret Faux: Well look, I don’t know. Convenience? I mean it’s a lovely idea to have a doctor come to you. It’s like getting home-delivery you know? And I guess now that if they know that it’s available… people don’t know what they need when it comes to their health. So this is pervasive right across the health literature, this concept called information asymmetry, which is basically just a fancy way of saying doctors know more about our health than we do. And what that means is there’s an unequal relationship in the room, because we don’t know what we need. We often need to go to a doctor to know whether we need to go to a doctor. So you can’t blame patients. You can never blame Australian consumers and patients because they’re doing their best, seeking out the healthcare that they need, and we have a fantastic healthcare system to support them. People don’t want to go to emergency departments. That’s not a pleasant experience – there’s long waiting times there. So everything about it is quite attractive in terms of getting someone to come and visit you.

Ellen Leabeater: Margaret Faux, CEO of Synapse Medical Services and PhD candidate at the University of Technology Sydney.

Female: You’re listening to Think:Health

Male: On 2SER 107.3.

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Ellen Leabeater: Recently on the show, we spoke about the lack of women being included in sport and exercise research. Well, the same can be said when it comes to nutrition for women during training. Up until recently, women were considered small men, and the nutrition advice given to them failed to take into account the physiological differences between men and women. Stacy T Sims is a senior research fellow at the University of Waikato in New Zealand. She spoke to us about what women need to do to get the most out of their training.

Stacy T Sims: Women, just like men, we have carbohydrates stored in our liver and in our muscles and this is what we primarily access when we start exercising. And then when we get into more of a steady state aerobic aspect, we use a little bit of body fat.

Ellen Leabeater: So that steady state is when you’re working really hard?

Stacy T Sims: When you’re working really hard doing high intensities, it’s primarily carbohydrate-driven.

Ellen Leabeater: Right.

Stacy T Sims: And part of the reason why high-intensity exercise like spin classes and cross-fit and that kind of stuff actually strip body fat down isn’t for the fact that you’re using fat during exercise, but it’s for the fact that you’ve driven up your core temperature and you have used all the carbohydrate in your liver and your muscle, so after exercise, your core temperature is up, which I guess, dissuades your body from storing body fat. And the fact that you’ve used all the carbohydrate, your body tries to restore the carbohydrate, so you end up using more fat at rest. So, it’s the combination of elevated core temperature and lack of carbohydrate that really strips the body fat down with high-intensity exercise.

Ellen Leabeater: What about for not-so-high-intensity exercise? So, for endurance athletes, how does it change? Does it change?

Stacy T Sims: So in the longer steady-state type exercise like hour, two-hour or onwards, you use a mix of carbohydrate and fat because you can’t sustain high intensity for that long, your body is looking at “how do I keep going.” And this is where you start getting into the whole how do you fuel for exercise, and the whole idea of x amount of grams per carbohydrate per hour to keep going is really a misnomer in the fact that most, if not all of the research has been done on men and primarily talented or elite trained men. Women’s intestines are a little bit different, in the fact that they have less ability to absorb fructose. It causes a lot of GI distress if we have too much fructose. So a typical sports-type gel or something like that is usually a mix of carbohydrates of maltodextrin and fructose and glucose. And fructose and maltodextrin don’t sit well in the female body. When we stat looking at fuelling perse, women do need some carbohydrate, but different mixture than what guys can handle. So this is where we start getting into a little bit of the details of how women’s body work differently from men.

Ellen Leabeater: This is something we’ve found actually quite recently that women are left out of sport and exercise research. Is there any research at all in regards to nutrition for women in the sport and exercise field.

Stacy T Sims: There is a little bit coming out. So, you have to be a little bit careful when you’re looking at it, because what happens in sport science research is only a small amount of funding and a short amount of time to get your study done. So women will come in as part of a participant group and they’ll be grouped in with the men and they’ll be doing the same thing as the men and when you go to extrapolate the results, they’ll just group the men and women together. And they’ll say “Yeah, this is a mixed gender study,” but it’s not really applicable. And the fact that when you’re looking at using female participants, you have to take that menstrual cycle into account, or where they are, if they’re using a birth control mechanism, are they well trained or not, and the fact of that is, when you’re in the low hormone phase, or the first two weeks of your period, and the fact that Day 1 is the first day of bleeding, up to two weeks after that. We’re very much like men. Our core temperature is lower, we can access carbohydrate pretty well, plasma volume is pretty similar. But when we hit ovulation and in the two weeks preceding our period, this is where things change. This is where our core temperature is up around 0.5 degrees Celsius, progesterone is very catabolic, so we don’t recover well, we tend to breakdown more muscle tissue. Progesterone also takes out more total body sodium, so we’re more predisposed to hyponatremia. Estrogen spares carbohydrates so we can’t hit the intensities, we can’t utilise the carbohydrate in our body very well, so in that factor, in those two weeks, this is why women aren’t necessarily included in sports science research because it creates too many confounding variables, it’s quote “too difficult” to study. And there’s a group of us, myself included in this, where we’re like, “No, that’s bullshit.” You need to study women. Women aren’t just two weeks of their cycle. We are this full complete twenty-eight day, thirty-two day. There are these perturbations that happen and we need to start investigating what is happening, because so many women will go for this fantastic workout and they can get this undue fatigue and feel like, “well, what’s going on, I’m not fit enough,” when it’s not their fitness, it’s their physiology, because of things that are changing within their body. So instead of blaming themselves or their fitness or not going hard enough, they need to realise, no wait, it’s your body’s response to what’s happening with these hormone perturbations and it is normal.

Ellen Leabeater: So do women need to be eating differently depending on what stage of their menstrual cycle they’re at when it comes to exercise?

Stacy T Sims: It’s not necessarily eating differently, it’s just paying attention to where they are in their cycle so they can recover well and they can fuel their workouts. Then from a recovery mechanism, really looking at what is your protein intake, especially within that 30 minutes after any kind of training session. I’m not saying go have a huge protein recovery drink right after your training, especially if you’re looking at calories in and calories out and that kind of stuff with recreational athletes trying to change body composition, but having (unclear) amino acids or a twenty gram whey protein hit, which is around 80 calories – it’s not a lot – but that goes so far with regard to recovery and building muscle and dampening down cortisol.

Ellen Leabeater: And is this applicable to women who are on the contraceptive pill as well?

Stacy T Sims: Yes. The thing about an oral contraceptive pill – most of them now days are low dose triphasics, so that means you have a step up of hormone doses across the first three weeks or your active pills and then you have a sugar pill week. But if we look at the bioavailability of those low dose hormones, it’s still higher than what your body naturally produces. So women on an oral contraceptive pill tend to be in a perpetual state of high hormone. So paying really close attention to how much protein you’re taking in and in particular in and around your training is going to go really far in changing body composition and allowing you to get better fitness adaptations. And in the sugar pill week, people will say, “Oh, well that’s a low hormone week” when in fact it’s not because your body rebound the first two days on the sugar pill week with oestrogen which can be akin to the first trimester of pregnancy. And all this kind of literature is in the fertility literature, which isn’t necessarily tapped into when you’re looking in the health and sports science literature. So drawing from all the different aspects that are out there and employing them together, we get a really good picture of what’s happening to a woman’s physiology and then how do you apply that when they’re actually in physical activity or training states, and how do we manipulate nutrition and training around what’s happening.

Ellen Leabeater: I know you mentioned protein earlier – that women should be having a little bit of protein after training. What about iron, because, you know, I’ve heard it said a lot that if you have your period and you exercise then you’re iron is low. Does that have any bearing on your performance?

Stacy T Sims: So, iron is a little bit of a longer conversation because it’s not just iron perse that we have to take into account. What I find typically in female endurance athletes is that there’s this residual information that’s always there because of the training stress and life stress. So there’s an up-tick in this liver enzyme called Hepcidin, and when you have an upper regulation of Hepcidin, you can’t absorb iron very well from the gut. So it doesn’t matter how much iron you’re taking in – if Hepcidin is up-regulated, you’re not going to aborb it. So it has nothing to do with what your period is in training, it has to do with how can you absorb iron. And women will be like, “Well, I’m anaemic or I’m borderline anaemic” and so they start taking iron supplements, but they’re still not absorbing it. So that’s one thing to get checked, it’s not just a blanket “need to take iron.” And then the other aspect is you don’t really lose that much iron during menstruation. If you are predisposed to low iron or you’re predisposed to anaemia, then yes, talking to a physician and taking a slow release iron supplement during those five or six days of bleeding will help mitigate some of the iron deficiency, but the blanket statement of high training and being a female who has regular menstrual cycle, you need to take iron, is not doing justice to the female population.

Ellen Leabeater: Stacy T Sims, Senior Research Fellow at the University of Waikato ending that story. And if you’d like to hear an extended version of that interview including how menopausal women should change their training, head to our website 2ser.com/thinkhealth.

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Ellen Leabeater: You’re listening to Think:Health on 2SER 107.3, online at 2ser.com or on your favourite podcast app.

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Ellen Leabeater: In central Australia, Alice Springs Hospital covers an area of 1.6 million square kilometres, and for many women, it’s the closest hospital with maternity services. Some women will travel 1000km just to give birth. A high proportion of women in this area are Aboriginal and experience poor maternal and infant health outcomes compared to non-Aboriginal women. In 2009, Alice Springs Hospital set up a midwifery group practice or MGP to improve the health outcomes for mothers and babies in this region. They set up two models of care. The first is for women who live close to Alice Springs. They are allocated their own midwife for anti-natal care and labour and the midwife will also see the new Mum for six weeks after the birth. The second model is for women in remote areas. They will be referred to the MGP from their local health service, which will liaise with the midwife in Alice Springs until the woman travels to the hospital to give birth. Bernadette Lack is a registered midwife who has worked in the Alice Springs MGP. She’s also researched the impact that the practice has had on the outcomes for women and babies.

Bernadette Lack: So, it’s a 189 bed specialist teaching hospital and it’s the only major secondary referral hospital in Central Australia. It’s catchment area covers approximately 1.6 million square kilometres and supports up to 60000 people residing in Alice Springs and in Central Australia and that covers communities in both South Australia and southwest of Western Australia.

Ellen Leabeater: Whoa, so it covers three states essentially?

Bernadette Lack: Yeah, the referral hospitals from Alice Springs… the closest referral hospitals are in Adelaide and Darwin, which are about 1500km north and south of Alice Springs.

Ellen Leabeater: And what sort of women do you see at Alice Springs Hospital giving birth?

Bernadette Lack: There’s women that reside in Alice Springs, and then there’s women that reside in remote Aboriginal communities across Central Australia.

Ellen Leabeater: Because I understand that if your covering so many million square kilometres that you’d have to travel quite far to have a baby.

Bernadette Lack: Yeah, so for women living in remote Aboriginal communities, there is a policy that those women have to transfer to a regional centre. So, for some women, that would be Darwin and for others it’s Alice Springs to give birth. Tennant Creek at the moment and during the study did not provide birth services for women, so some women would travel 1000km. Katherine also provides some birthing services and so does Gove. There’s five hospitals in the Northern Territory. Four out of the five offer birth services, and so all women in the Northern Territory living in remote communities, from 36-38 weeks, transfer to a regional centre for birth.

Ellen Leabeater: So your research has looked at the outcomes for mothers and babies. What were the outcomes for the babies?

Bernadette Lack: So we had really lovely outcomes with low birth weight babies. That was one of our major findings. So we know low birth weight increases the risk of chronic disease later in life, and it’s a key indicator of health status. Nationally, for babies born to Aboriginal women, the low birth weight occurs in about 12.6% of births. For non-Aboriginal babies, it’s around 6%. In the Northern Territory this is much higher. So for babies born to Aboriginal and Torres Strait Islander women, it’s around 16%, which is around about three times more than babies born to non-Aboriginal women. But in the MGP, our overall rate was 5%. For Aboriginal and Torres Strait Islander women it was 7% and for non-Aboriginal and Torres Strait Islander women it was 3%.

And then with pre-term birth, we know pre-term birth is the leading cause of neonatal death worldwide and child mortality under 5 in high and middle-income countries. And it’s a priority of the closing the gap campaign. So in Australia, the pre-term birth rate is around 8.3%. In the Northern Territory it’s around 11.1%. Overall for MGP it was around 6%. Specifically, for Aboriginal babies in the Northern Territory, it’s around 16% and the MGP recorded a 9% rate, so almost half.

Ellen Leabeater: So why do you think the rates for pre-term birth and low birth weight are so reduced in the MGP?

Bernadette Lack: So, the international and national evidence on midwifery continuity of care shows specifically for pre-term birth that there is a 24% reduction in pre-term birth with midwifery continuity of care, and we’re not sure why that is, so we definitely need some more research into that area to find out why… certainly our results of our study were consistent with national and international research on the benefits of continuity of midwifery care.

Ellen Leabeater: And Bernadette, what about the mothers? What were the outcomes for the mother’s like?

Bernadette Lack: We know that antenatal visits, the WHO recommends four antenatal visits for positive maternal and child health outcomes and same with early access to antenatal care. So accessing antenatal care before 13 weeks, we know that pre-term birth, low birth weight and perinatal death increases if antenatal visits decrease. So, in our MGP, over 90% of Aboriginal women in the MGP accessed five or more appointments. And that’s also consistent with NT data, that’s around 90% as well, but that’s a combined Aboriginal and non-Aboriginal number. And we also had, so, the early access to antenatal care nationally it’s around 65.7% in the first trimester. In the Northern Territory it’s 71% and in the MGP we had a 74% rate of early access to antenatal care (unclear).

Ellen Leabeater: Bernadette Lack, registered midwife ending that story.

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Ellen Leabeater: Don’t forget, if you’d like to find out more about anything you’ve heard today, you can visit us at 2ser.com/thinkhealth. We’re also available on demand. Just search for Think:Health in your favourite podcast app.

Please remember that journalists are not doctors. If we’ve made you ask questions, go and see your GP. This show is produced with the support of the University of Technology, Sydney, Faculty of Health. I’m Ellen Leabeater, see you next week for more in health research and news.

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