Volume 208 Issue 3

Gifted funding runs the risk of bypassing peer review

Anthony F Jorm

Conversations are key to changing behaviours in a complex health care system

Robyn Ann Lindner

The RACP emphasises the need for caution until there is sufficient quality evidence to support the use of medicinal cannabis

Jennifer H Martin · Yvonne Bonomo · Adrian DB Reynolds

Concepts of epidemiology: integrating the ideas, theories, principles, and methods of epidemiology; 3rd edition

Lisa Hall

Three hospitality workers presented to a Sydney tertiary hospital emergency department within a 24-hour period with vague neurological symptoms

Amy Kunchok · Penelope J Spring · Michael W Hayes

Making iodine fortification of bread mandatory in Tasmania successfully improved population iodine levels

Kenneth J Harvey · Basia O Diug

It is time to examine how the health of young women can be improved prior to pregnancy

David A Ellwood · Leonie K Callaway

Additional health care, particularly for chronic diseases, is provided at most GP administrative encounters

Lyndal J Trevena · Christopher Harrison · Helena C Britt

Objective: To examine the prevalence across 25 years of overweight and obesity among nulliparous Australian women during early pregnancy; to estimate the proportions of adverse perinatal outcomes attributable to overweight and obesity in this population. Design: Cohort study; retrospective analysis of electronic maternity data. Setting, participants: 42 582 nulliparous women with singleton pregnancies giving birth at the Royal Prince Alfred Hospital, an urban teaching hospital in Sydney, January 1990 – December 2014. Main outcome measures: Maternal body mass index (BMI), socio-demographic characteristics, and selected maternal, birth and neonatal outcomes; the proportion of adverse perinatal outcomes that could be averted by reducing the prevalence of overweight and obesity in women prior to first pregnancies (population attributable fraction, PAF). Results: The prevalence of overweight among nulliparous pregnant women increased from 12.7% (1990–1994) to 16.4% (2010–2014); the prevalence of obesity rose from 4.8% to 7.3% in the same period, while the proportion with normal range BMIs fell from 73.5% to 68.2%. The PAFs for key adverse maternal and neonatal outcomes increased across the study period; during 2010–2014, 23.8% of pre-eclampsia, 23.4% of fetal macrosomia, and 17.0% of gestational diabetes were attributable to overweight and obesity. Were overweight and obese women to have moved down one BMI category during 2010–2014, 19% of pre-eclampsia, 15.9% of macrosomia, 14.2% of gestational diabetes, 8.5% of caesarean deliveries, 7.1% of low for gestational age birthweight, 6.8% of post partum haemorrhage, 6.5% of admissions to special care nursery, 5.8% of prematurity, and 3.8% of fetal abnormality could have been averted. Conclusions: Over the past 25 years, the proportions of adverse perinatal outcomes attributable to overweight and obesity have risen with the increasing prevalence of maternal overweight and obesity. A substantial proportion of these outcomes might be averted with obesity prevention strategies that reduce pre-pregnancy maternal weight.

Kate Cheney · Rachel Farber · Alexandra L Barratt · Kevin McGeechan · Bradley de Vries · Robert Ogle · Kirsten I Black

Ongoing monitoring of population iodine nutrition is needed to prevent a return to iodine deficiency

Kristen L Hynes · Judy A Seal · Petr Otahal · Monique A Reardon · John R Burgess

Menopausal symptoms are often the most persistent and troubling effects of cancer treatment

Jennifer L Marino · Helen C McNamara · Martha Hickey

Cannabidiol may be a treatment option but high quality trial data are needed to guide medical decisions, policy and legislation

Kerrie-Anne Chen · Michelle A Farrar · Michael Cardamone · John A Lawson

Updated guidelines for melanoma excision margins promote optimal practical management of primary cutaneous melanoma

Michael J Sladden · Omgo E Nieweg · Julie Howle · Brendon J Coventry · John F Thompson

To the Editor: I read with some concern the study by Ibrahim and colleagues1 published in the Journal. In their epidemiological study of deaths of nursing home residents reported to the coroner, the authors reported a more than quadrupling of the rate of deaths due to falls over the decade from 2002 to 2012, and deemed these deaths to be preventable and premature. In their discussion, Ibrahim and colleagues1 insinuate that this increased rate of deaths due to falls relates to some extent to a decline in the standard of care provided to nursing home residents. As this study lacks a control group, fundamentally, there is a problem in making any assumptions about preventable deaths and care provided to nursing home residents. This problem is particularly pertinent in light of data published by the Australian Institute of Health and Welfare which show an almost 40% increase in the rate of injury hospitalisations for older Australians, predominantly due to falls, over a similar 10-year period.2 A subsequent publication by the Australian Institute of Health and Welfare reports that 50% of all falls in older people resulting in hospitalisation occur in or around the home and that only 22% occur in an aged care facility.3 Therefore, one could ask whether there has been a similar increase in the rate of premature and preventable deaths due to falls of older Australians who live in their own homes. Clearly, further research on falls in general is required before any conclusions about possible causes can be made.

Henry Zeimer

To the Editor: Ibrahim and colleagues1 are to be congratulated for finding a source of information that throws some light on what is happening in Australian aged care facilities, because there is so much positive rhetoric and so little reliable data about aged care coming from the sector itself. The study by Ibrahim and colleagues1 reveals an increase in deaths from external causes, including falls and choking, but we need context. In his 1993–94 report, Gregory2 indicated that in the proposed market-driven aged care system “neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit”. However, the government policy is driving consolidation and corporatisation using a competitive profit-driven model. International data indicate that an increased focus on profitability in aged care is associated with poorer staffing and increased failures in care.3 Studies in Australia and the United States over the past 35 years indicate that, on average, 4 hours or more per person per day of nursing care are required for safe care. Available data indicate that, in Australia, only 2.8 hours are provided. As acuity has increased, the proportion of trained staff has fallen. Our residents receive less than half the nursing time from registered and trained nurses compared with the US and an hour less of total nursing care each day.3 Safe care cannot be provided with these staffing levels; yet, over 95% of facilities are accredited by the Australian Aged Care Quality Agency. Braithwaite and colleagues,4 who have studied the regulation of aged care, conclude that aged care regulation has been captured by the market and is ineffective and warn that “the community should be concerned”. While politicians and the industry talk up our system, it is becoming increasingly clear that the many failures (often in recently accredited facilities) reported in the press are red flags to systemic problems that a succession of captured inquiries into a system that is anything but world class have avoided addressing. With some exceptions, our profession seems to have disengaged from the sector and one wonders if they have been captured too.

J Michael Wynne

To the Editor: The study published by Ibrahim and colleagues1 raises questions about the quality of care delivered in residential aged care facilities. This analysis of routinely recorded coronial data identified that 15% of premature and preventable residents’ deaths resulted from external causes, with falls being the most frequent culprit. Falls in residential aged care facilities are well recognised, with about half of all residents falling within a given year.2 Residents tend to be older and frailer, have higher rates of dementia and higher rates of psychotropic medication use compared with community-dwelling older people, which contributes to higher rates of falls. A falls risk assessment, using validated tools and appropriately qualified personnel, has the potential to reduce the rate of falls and related injuries by addressing individual and environmental risk factors.3 While the residential aged care sector is subject to variation in staffing numbers and skill mix, mandatory education related to falls prevention is also needed. The Australian Commission on Safety and Quality in Health Care’s Preventing falls and harm from falls in older people — best practice guidelines for residential aged care facilities4 provide a helpful framework. In a separate study, Ibrahim, the lead author of the MJA article, and Davis5 state that residents in aged care facilities are entitled to the “dignity of risk” principles that allow them autonomy to accept risks that may be associated with short term increases in their quality of life. However, the reality is that a person’s quality of life is often determined by risk management rather than autonomy,6 which reflects a form of age discrimination whereby the risk of injury of falls and its consequences outweighs the older person’s quality of life, by making assumptions about their ability to make choices about their everyday activities. Promoting dignity and autonomy for older residents in aged care may see greater falls rates but it will allow residents to enact their choices. The work by Ibrahim and colleagues1 needs to be understood within this context.

Judy A Lowthian · Claudia Meyer · Dianne Goeman · Colette Browning

In reply

Joseph E Ibrahim · David L Ranson · Lyndal Bugeja