Volume 215 Issue 3

To protect themselves from the potential harms of low value care, patients must take an active role in clinical decision making Low value care is care that is ineffective, harmful or confers marginal benefit at disproportionately high cost.1 Professionally‐led campaigns such as Choosing Wisely Australia and the Royal Australasian College of Physicians’ EVOLVE program aim to reduce the prevalence of such care. However, similar overseas campaigns have been marred by selective focus on infrequent, low impact, or less financially lucrative practices;2 uncertainty about the most effective de‐adoption strategies;3 and limited success to date in reducing overuse.4 While clinician‐targeted education programs, audit and feedback, and decision support feature prominently, evidence appears stronger and impact seems greater for strategies directed to, or mediated by, patients.5 Framing low value care as a health hazard for patients Although clinicians accept responsibility for resource stewardship, they also believe their primary care obligation is to the individual patient, with costs being a secondary consideration.6 Most patients hold similar views, until out‐of‐pocket expenses become unaffordable.7 Reframing low value care as having negative consequences, not just “worth a go” or “better safe than sorry”, may incentivise patients, clinicians and policymakers to engage more in mitigation efforts.8 Negative consequences can arise directly from an episode of low value care, or indirectly from subsequent downstream care cascades, such as invasively investigating incidental but benign findings from a previous unnecessary investigation. Harms can be physical, psychological, social, financial and relational (mistrust). Even providing potentially beneficial care to patients who do not want it can cause harm, at least psychologically. Moreover, giving low value care to one individual may result in delayed delivery of high value care to another individual, who may then suffer preventable harm. The burden of negative consequences Recent studies have begun to quantify the negative consequences of different forms of low value care. A review of 54 case descriptions of 63 overused services revealed an average of 3.2 negative consequences per case, most (33/54, 61%) featuring an overuse cascade feedback loop.9 Reported harms (91 in total) comprised injury (69%), psychological harm (16%), treatment burden (9%), financial loss (3%), and dissatisfaction (2%).9 Recent care cascades were reported by 374 internists in the United States following incidental findings from tests that a third deemed clinically inappropriate but which led to a new invasive test (77.2% of instances), an emergency department visit (54.8%), or hospitalisation (50.6%).10 These caused patients physical (15.6%) or psychological harm (68.4%), financial loss (57.5%), social disruptions (8.7%), and dissatisfaction (27.6%).10 Seven low value procedures characterised 9330 admissions to 225 Australian hospitals, including endoscopy for dyspepsia or colonoscopy for constipation in young people, knee arthroscopy for osteoarthritis or meniscal tears, and spinal fusion for uncomplicated low back pain.11 Between 0.2% and 15.0% of patients, depending on the procedure, developed one or more hospital‐acquired complications, most commonly infection (26.3% of instances), with a twofold or more increase in the median length of stay.11 Among 72 unnecessary admissions to one US hospital of low risk syncope patients, one in eight had an adverse event from tests and treatments.12 In a study of 405 695 individuals with new onset, non‐specific low back pain, those receiving lumbar spine magnetic resonance imaging (MRI) within 6 weeks, compared with matched controls without an early MRI, incurred significantly more surgery (1.48% v 0.12%), greater opioid use (35.1% v 28.6%), and worse pain scores (3.99 v 3.87).13Among 5057 individuals with incidentally detected lung nodules on chest x‐rays, those receiving intense diagnostic investigation versus guideline‐concordant care had more procedure‐related adverse events (8.1% absolute increase) and more radiation exposure, with no higher incidence of advanced cancer at 2 years’ follow‐up.14 In a study of 1488 hospitalised patients who received antibiotics for at least 24 hours, 287 (19%) of the antibiotic regimens were not indicated (eg, asymptomatic bacteriuria, aspiration pneumonitis, congestive heart failure), with 56 (20%) being associated with an adverse drug event, including seven cases of Clostridium difficile infection.15 Adding aspirin with no clear indication to 1107 of 3280 patients (33.8%) prescribed direct oral anticoagulants (DOACs) for confirmed indications was associated with more bleeding events (31.6 v 26.0 bleeding events per 100 patient years) and hospitalisations (9.1 v 6.5) than matched controls receiving direct oral anticoagulants only.16 The role of patients in reducing low value care While clinicians often complain of patients demanding inappropriate care,7 many patients perceive the negative consequences of overuse,17 and interventions that empower patients to challenge such overuse are effective in decreasing it by 25–40%.18 In a review of 22 studies, 19 (86%) reported significant reductions in unnecessary use of antibiotics and benzodiazepines, Caesarean deliveries, elective labour inductions, surgery for knee and hip osteoarthritis, non‐beneficial intensive care treatments, computed tomography scans for mild head injury in children, cardiac stress testing in low risk adults, and routine screening tests (full blood counts, electrocardiograms).18 These empowerment interventions comprised patient‐oriented educational materials and shared decision‐making protocols, the latter having greater effect. In another study, encouraging patients to identify their health concerns before a clinical encounter, and increasing their knowledge about their condition and care options, also rendered clinician advice more concordant with best practice by 33–60%.19 However, successful engagement depends on several factors: motivation and ability of clinicians to engage patients in decision making; clinician knowledge of, and agreement with, what constitutes low value care; the clinical context; and availability of decision support resources for both parties within clinical workflows. Clinicians do not always attempt to facilitate patient involvement and may not adjust care to patient preferences.20 Such engagement is time‐consuming for clinicians and inadequately remunerated, impractical in emergency situations or for patients unable or unwilling to engage, and may incite patient anxiety or dissuade them from further consultations. In response, evidence‐based strategies can overcome these barriers21 and reinforce patient perceptions of receiving optimal care and their desire to reconsult. More research needs to define the most effective mix of techniques for supporting patient engagement (eg, educating clinicians on communication techniques, deploying multidisciplinary teams, using trained decision coaches and patient decision aids), and their effects on consultation time and costs.22 Whether such engagement, by specifically reducing low value care, actually improves patient health remains uncertain, although its absence predisposes to worse clinical outcomes, lower quality care and increased health care utilisation.23 Empowering patients to engage in reducing low value care Many patients refrain from participating in discussions aimed at avoiding overuse because of a power asymmetry wherein they sense the need to seek clinician permission to discuss their options, feel they have insufficient knowledge to ask pertinent questions or understand the jargon (“doctor knows best”), and fear repercussions from being seen to challenge clinician credibility (desire to be a good patient). Alternatively, patients may want to avoid responsibility for making a wrong decision they will later regret, or feel unable to participate because of illness symptoms, cognitive impairment, language or cultural barriers, or need for emergency or intensive care.17 Nevertheless, clinicians must avoid making false assumptions about how much a patient desires involvement in decision making. Methods are needed for identifying which patients, encounters and clinicians need more support to enact the most appropriate form of shared decision making. Patients usually desire a more active role when the matter is serious, invasive interventions are being considered, or if significant out‐of‐pocket costs, lengthy time off work, or interruptions to social activities may be incurred. Younger patients, women and those with higher educational and socio‐economic status are more likely to participate.24 Greater engagement and less overuse are seen within long term clinician–patient relationships characterised by mutual trust and continuity of care,25 and where public messaging within practice environments encourages and legitimates engagement.26 Patients can be trained to ask questions, and adult learning programs can assist those with low health literacy.27 Choosing Wisely Australia (www.choosingwisely.org.au) and other organisations28 provide conversation starter patient resources; other sources provide topic‐specific lists of questions (eg, www.prosdex.com for prostate‐specific cancer antigen testing, and www.bresdex.com for breast cancer surgery). Decision aids, option grids and fact boxes can also assist. As a minimum, patients should be encouraged to ask these questions: Is there a decision we need to make? In urgent situations, clinicians may need to reach out and not wait for patients to ask. What are my options? All clinically viable options should be presented, including doing nothing. What are potential benefits and harms of each option? Where possible, these should be expressed using natural numbers (eg, four out of 100 people like you will experience a stroke every year; this treatment will reduce that to two out of 100, although one person of 100 will have a significant bleeding event). How will each option affect me in terms of what I consider important? Patients may want to know costs involved, duration of inability to work or perform social activities, skill and place of those performing a procedure. Consumer organisations should be resourced to run community education campaigns focused on engagement, while clinicians must be educated about the benefits of patient engagement and receive the tools, time and remuneration to support it within busy work schedules. Conclusion Efforts to increase patient empowerment in decision making should be seen as foundational for reducing low value care, and should underpin all other strategies targeting clinicians, payers and policymakers.

Ian A Scott · Adam G Elshaug · Melissa Fox

Risk‐based testing is failing a third of people living with chronic hepatitis B in Australia The United States Preventive Services Task Force recently issued new guidance that all adults aged 18–79 years should be offered screening for hepatitis C virus infection,1 expanding on prior risk‐ and age‐based recommendations. The rationale is that hepatitis C virus infection is a common condition (estimated 1% prevalence) that is leading to an increasing burden of disease from cirrhosis and liver cancer, it is easy to test for, there are well tolerated and highly effective treatments available, and treatment costs have dropped substantially in the past 5 years. The guidance acknowledges that risk‐based screening has been insufficient in increasing the number of people diagnosed and able to access treatment, and further change is needed to address the ongoing burden of adverse outcomes. In Australia, an estimated 80% of people living with hepatitis C have been diagnosed,2 and treatment uptake is among the highest in the world; however, progress in diagnosing people living with chronic hepatitis B is much less impressive. We argue that Australian guidelines for hepatitis B screening should be similarly changed and expand from a risk‐based approach to a more universal one. Hepatitis B is a condition that affects more than 225 000 Australians,3 and when untreated, it leads to serious adverse outcomes such as liver cirrhosis and cancer in up to one‐quarter of people affected despite being generally asymptomatic.4 Infant vaccination in Australia since 2000 has reduced local transmission,3 but hepatitis B is most commonly acquired at birth or in early childhood when there has been inadequate access to vaccination, and it disproportionately affects Australians born overseas.2 While a cure is not yet available, highly effective antiviral treatments can be accessed through Medicare which have been shown to reduce liver cancer risk by up to 70% within 5 years.5 Based on this evidence, treatment for hepatitis B is recommended in national and international guidelines when there is either cirrhosis or ongoing liver inflammation to reduce morbidity and mortality associated with hepatitis B virus infection. Australia’s National Strategy for Hepatitis B sets the target of 80% of people diagnosed by 2022, but this proportion has barely improved in recent years, from 63% in 2011 to 69% in 2018.3 Although about 6000 people6 are newly diagnosed with hepatitis B each year, the number of people living with hepatitis B in Australia has continued to increase due to the addition of people who acquired the disease in their country of birth (Box).7 This leaves an estimated 71 000 Australians (plausible range, 32 000–93 000) undiagnosed and at risk of significant adverse outcomes. As this estimate is reliant on underlying model estimates — incorporating data on migration, natural history, immunisation and transmission7 — these data are subject to uncertainty. However, even accounting for this uncertainty, it is estimated that there is only a 4.6% chance that Australia will reach the 2022 target of 80% of cases diagnosed.3 The late diagnosis of hepatitis B in an individual is a missed opportunity for that person to receive appropriate care, including antiviral treatment to prevent liver cancer and cirrhosis.5 In New South Wales in 2011–2012, 29% of people diagnosed with hepatitis B‐related liver cancer were diagnosed late (< 2 years before their cancer diagnosis).8 Failure to diagnose not only affects the individual but is a missed opportunity for family members to be appropriately screened and receive vaccination to prevent transmission of hepatitis B within households. Data indicate only a third of people requiring antivirals to prevent liver cancer or cirrhosis are currently receiving them in Australia.7 Increasing the percentage of people receiving treatment to 20%, as per the National Strategy target, would prevent an estimated 1700 deaths by 2030.7 Improving diagnosis is key to meeting these treatment targets. For over 25 years, the diagnosis of most people affected by hepatitis B in Australia has relied on risk group‐based screening. The National Hepatitis B Testing Policy lists 16 indications and 13 risk groups that should be considered for testing. Universal screening is only recommended during antenatal care, and a substantial proportion of women are first diagnosed with hepatitis B at this time. For clinicians, conducting a guideline‐based ascertainment of risk is complex, requiring knowledge of country of birth; Indigenous status; history of travel, vaccination, incarceration, and medical procedures; occupation; sexual activity; family history; and previous or current injecting drug use. There is limited evidence regarding the acceptability and uptake of these recommendations, but research assessing general practitioner attitudes to hepatitis B has identified discomfort with profiling patients based on cultural background.9 A study of GPs identified that 33% were not aware people from these communities are the main at‐risk population for hepatitis B, and 67% agreed that assistance with identifying patients who should be tested was needed.10 This targeted approach to testing can also contribute to the experience of stigma and discrimination among people affected by or at risk of hepatitis B, particularly given the structural and health care inequalities experienced by many members of these groups. Chronic hepatitis B meets all the World Health Organization criteria for disease screening:11 it is an important health problem for the person and the community; highly accurate diagnostic tests are available; there is typically a long asymptomatic period of infection; treatments are available and they are more effective when started earlier in the course of the disease; and based on cost‐effectiveness studies, the cost of diagnosis and treatment is economically balanced in relation to health care costs as a whole. A further advantage with hepatitis B is that, given the availability of a highly effective vaccine and the generally lifelong nature of infection, screening will usually only need to be done once. Subsequently, one‐time screening will simplify patient engagement in regular follow‐up and monitoring, with most needing annual recall for reimbursed blood tests and liver ultrasounds (for Medicare‐eligible people, the majority of Australians living with hepatitis B). Community engagement strategies including community codesigned and place‐based outreach programs will also be essential. Although some hepatitis B community outreach occurs in Australia, it is profoundly underfunded compared with other community programs such as those for the human immunodeficiency virus (HIV), and increased investment will be central to supporting a more universal testing approach. The prevalence at which hepatitis B screening is cost‐effective has been estimated at 0.3%12 (United States) and 0.41%13 (the Netherlands), well below Australia’s estimated prevalence of 1%.7 Although further study is needed to assess local cost‐effectiveness of screening, the management and treatment of people diagnosed with hepatitis B has been found to be cost‐effective in Australia. A 2009 study found that appropriate treatment was not only cost‐effective but more so than many currently existing population‐based cancer prevention programs.14 More recent research has also suggested that improving the hepatitis B cascade of care in Australia is cost‐effective.15 The current risk‐based screening approach for hepatitis B in Australia has failed to meaningfully increase the proportion of people diagnosed with this disease in the past decade, and we argue that it is time for a radical rethinking of our approach to testing for hepatitis B. Although difficult to quantify due to crossover in populations, given the breadth of the existing screening criteria — including all women who have been pregnant in the screening era (3.5 million Australians), all migrants from countries with more than 2% prevalence (2.1 million), all Aboriginal or Torres Strait Islander people (850 000), all adults at higher risk of infection (1.4 million), and any person with existing liver disease (over 5 million) — it is likely that most of Australian adults meet least one screening criteria, and a universal approach would represent a relatively small expansion in the total number eligible. We believe that guidelines should now recommend that all Australians aged 20–79 years whose hepatitis B status has not been documented should be offered testing. This minimum age coincides with the enactment of universal hepatitis B vaccination in Australia, which led to a substantial reduction in prevalence. However, screening would still be required in cases where a child was born overseas or was born in Australia to a mother living with hepatitis B. The upper age limit for offering testing may not reach cost‐effectiveness thresholds; however, this has not been locally established and there is evidence that older Australians have a considerable burden of hepatitis B6 and liver disease.7 Offering testing should always be conducted within the context of informed consent,16 and given most tests currently take place in primary care settings, GPs should be supported to incorporate hepatitis B screening into standard preventive health care for all adults.2 In line with Australia’s historical approach to blood‐borne virus responses, involvement of community and professional organisations and people with lived experience should be central to implementation. There is a need to change the way we approach testing for hepatitis B in Australia as we fail to meet both interim and longer term targets.7 Innovation and simplification of our testing policy are necessary to reach people unaware of their risk, encourage clinicians to test, and reduce stigma and discrimination associated with questioning people about risk factors. This approach would help integrate routine hepatitis B screening and care into primary care. A fundamental change is needed if Australia is to meet our National Strategy targets for 2022 and the WHO elimination targets for 2030. Importantly, it would allow the more than 70 000 Australians with undiagnosed hepatitis B7 to be informed about their condition and to enable them to access care and potentially life‐saving treatment. To not do so will further entrench the status quo and the ongoing preventable morbidity and mortality associated with late diagnosis of hepatitis B.7,8 Box – Trends in chronic hepatitis B diagnosis in Australia during 2010–2019, incorporating modelled estimates of diagnosed and undiagnosed population (area) and annual surveillance notifications of newly diagnosed cases (line) Modelled data sourced from previously published work.7 Annual number of notified cases sourced from the Australian Government Department of Health National Notifiable Diseases Surveillance System.6

Nicole L Allard · Jennifer H MacLachlan · Lien Tran · Nafisa Yussf · Benjamin C Cowie

Lubel JS, Roberts SK, Strasser SI, et al. Australian recommendations for the management of hepatocellular carcinoma: a consensus statement. Med J Aust 2021; 214: 475‐483. https://doi.org/10.5694/mja2.50885 In this Consensus statement, on page 475, where it says “These recommendations summarise the complete document, available at https://www.gesa.org.au/resources/hepatocellular-carcinoma-hcc-management-consensus/”, it should read: “These recommendations summarise the complete document, available at https://www.gesa.org.au/resources/hepatocellular-carcinoma-hcc-management-consensus/. The full list of endorsements is available in the online Supporting Information”. An online Supporting Information document has also been added.

A 62-year-old man presented with left eye swelling and 3 weeks of intermittent epiphora without visual disturbance

Douglas Dunn · Sebastian Brown · Sartaj Sandhu · Domit Azar

A 75-year-old woman presented to her general practitioner with several weeks of dyspnoea

Jessica Phillips · Jonathan Foo

A 29-year-old Korean woman presented with a pruritic, reticulate, red-brown, papular eruption overlying her clavicle and neck, occurring in the setting of carbohydrate restriction

Blake P Mumford · Anita Lasocki

Laws requiring doctors to report consensual adolescent sexual activity present legal, clinical and ethical problems Many Australian teenagers engage in consensual sexual intercourse with similar aged peers.1 They require confidential medical care, including contraception and sexually transmitted infection testing. However, adolescents’ rights to access medical care may confront legal barriers. In several Australian states and territories, new criminal laws require adults to report sexual offences against children. Other criminal laws make it an offence for adolescents aged under 16 years to engage in sexual intercourse. Accordingly, a question for clinical practice is whether the new criminal law reporting duty applies to adolescents’ confidential communications regarding consensual sexual activity. Law, ethics and practice must protect children, but must not criminalise consensual peer sexual activity or compromise clinical care. Here, we review literature regarding adolescents’ lived experience, findings from developmental science, and analyses of consensual and lawful sexual activity. We conduct a comparative analysis of Australian criminal law reporting duties for child sexual offences. We identify situations where laws inappropriately require clinicians to report adolescent sexual activity, and we make recommendations for reform. Background A 2018 national survey found 47% of 14–18‐year‐olds engaged in vaginal or anal intercourse, including 34% of those in Year 10.1 For most Year 10s (aged 14–16 years), the most recent sexual partner was a peer aged under 17 years (92%). However, 6.5% of sexually active Year 10s reported their most recent partner was aged 18–19 years. Of Year 10 females, over one‐third (37%) had engaged in intercourse, and for 10% of these their most recent partner was aged 18 years or older. General practitioners were the most trusted source of sexual health information, from whom 40.6% of females sought clinical advice.1 Clinician engagement was further evidenced by 43.5% of females using the contraceptive pill. However, adolescents experience multiple barriers in accessing health services, including perceived lack of confidentiality, and youth friendly service guidelines recommend confidential care approaches.2,3,4 The Lancet commission on adolescent health acknowledged the complex interplay of adolescent neurodevelopment and legal principles of capacity.5 Australian legal milestones differ, indicating how laws attempt to attain policy goals while grappling with scientific knowledge: 10‐year‐olds can be liable for criminal offences; 15‐year‐olds can obtain a Medicare card; and 17‐year‐olds can drive. Developmental neuroscience has shown adolescents aged 15–16 years possess adult‐like cognitive ability,8,9 while psychosocial and neurobiological maturity continues into the mid‐20s.8 It has been shown that, especially when in “calm and emotionally‐neutral contexts”,5 adolescents possess cognitive capacity to weigh costs and benefits and make reasoned judgements about courses of action, including about consenting to medical treatments involving contraception and sexual health.6,7 Much consensual peer sexual activity occurs in such settings; even in more emotionally “hot” circumstances, the capacity to consent to sex with similar aged peers is consistent with findings from developmental neuroscience. Legal requirements for consent, and the age of consent Lawful consent to sex requires full, free and voluntary agreement, and the absence of threat, intimidation and abuse of power (Box 1). Social science models of child sexual abuse are similarly premised on consent requiring full, free, voluntary and uncoerced participation.10 Laws must navigate a tension between protecting the developing adolescent and respecting and promoting their capacity and autonomy.11,12 In this setting, legislatures, as the bodies in each state and territory able to pass and amend criminal laws (legislation), must protect children and youth from sexual abuse, while allowing consensual peer sexual activity in both heterosexual and same‐sex relationships. Currently, the legal age of consent prohibits intercourse with minors under a specified age, presuming that children under this age lack capacity to provide true consent. This age is 16 years in most jurisdictions (Box 2). Legal defences embody legislatures’ acknowledgement that sex between adolescents may be consensual and permissible. Criminal laws in five jurisdictions provide a close‐in‐age defence to offences where the act involves consenting people who are both minors aged under 16 years or are similar in age (Box 2). Prosecution guidelines Similarly, official guidelines in every jurisdiction13,14 regarding prosecution of criminal offences recommend against prosecuting consensual activity between minors. These guidelines acknowledge it is against the public interest to prosecute these cases, because of the oppressive consequences, and the trivial and merely technical nature of any breach. Victoria’s guidelines are particularly strong, and specifically refer to situations where both adolescents are under 16 years of age, and where they are aged 15 and 18 years: a prosecution is contraindicated where a young person “has committed an offence in the context of a consenting sexual relationship with another young person [including] sexual penetration of a child under 16 where the offender is 18 and the complainant is 15”.13 In such cases, prosecutors should consider: the adolescents’ ages and maturity; whether they are in a relationship; whether they consented; and whether the person wishes a prosecution to proceed.13 In our hypothetical clinical case of Anna and David (Box 3), a prosecutor should conclude that despite technical commission of an offence (due to Anna and David being 15 and 18, respectively), prosecution should not occur because they are mature, near aged peers in a consenting sexual relationship with no coercion. They were responsibly acting to obtain contraception and advice from a medical practitioner, and Anna would not want David prosecuted. Prosecution is against the public interest for reasons including adverse effects on adolescents’ willingness to seek medical advice, which may result in further consequences including unintended pregnancies, sexually transmitted infections, and effects on education, employability and health. Criminal law reporting duties Child protection legislation has long required professionals to report sexual abuse to child welfare agencies.15 Recent inquiries into institutional abuse and cover‐ups catalysed recommendations for new reporting duties in criminal law, applied to all adults.16,17 Victoria, New South Wales, the Australian Capital Territory and Tasmania have since enacted new reporting duties in criminal law, advancing social norms to protect children.15 Queensland has recently enacted a duty, which has not yet commenced. (Supporting Information, Table 1). These laws require adults to report information to police about a sexual offence committed against a child. To accommodate exceptional circumstances and navigate ethical tensions, exceptions apply to requests of non‐disclosure, and confidential disclosures (Supporting Information, Table 1). Comparative analysis: six dimensions of legal inconsistency and uncertainty The relevant laws differ between jurisdictions, and exceptions are of uncertain application. Comparative statutory analysis reveals that for medical practitioners treating adolescents in consensual peer relationships, the laws present six problems. First, only NSW expressly excludes medical practitioners from the duty to report sexual offences against children (Supporting Information, Table 1). This creates a clear inconsistency: NSW practitioners are exempt from the duty, while their counterparts elsewhere are not. However, exempting NSW practitioners may mean sexual offences are less likely to be reported. Second, three jurisdictions apply the duty to report sexual offences both to situations involving two minors aged under 16 and to situations involving a minor and an adult. In contrast, Victoria only applies the duty to situations involving a minor and an adult. Accordingly, Victoria’s duty is narrower, acknowledging that otherwise it may inappropriately embrace consensual behaviour; yet it is important not to discourage Victorian practitioners from reporting non‐consensual sexual offences between minors, so this limit may be suboptimal. The problem elsewhere is that the duty may capture consensual peer activity. Third, only Victoria excludes the duty where the adolescent “victim” aged 16 or 17 requests non‐disclosure. Elsewhere, this exemption applies only to requests by victims aged 18 or over. This creates inequality in recognising adolescent capacity and autonomy. Fourth, the concept of a “reasonable excuse” for non‐reporting is not exhaustively defined (Supporting Information, Table 1). It is unclear whether a reasonable excuse for non‐disclosure includes a medical practitioner’s choice not to report a confidential disclosure in a therapeutic setting of consensual acts constituting a sexual offence. This leaves practitioners in all jurisdictions unsure whether they would be legally protected for not reporting. Fifth, Victoria, NSW and Tasmania enable prosecution only if approved by the Director of Public Prosecutions. This suggests multiple situations do not warrant prosecution. However, it is not clear when approval would be given, leaving clinicians in doubt about exemptions to the duty. The ACT lacks this mechanism, indicating higher likelihood of prosecution. Sixth, health professionals may be exempt from the duty where a patient confidentially discloses a sexual offence (Supporting Information, Table 1). This exemption is founded on the concept of professional confidential relationship privilege. However, these exemptions are unclear, rely on networks of laws, and apply to different practitioners. Tasmania and the ACT lack clear confidentiality exceptions (Supporting Information, Table 2). NSW has a clear exemption. Victoria has an express exemption if the information is a “confidential communication” as defined by other legislation (Box 4). However, in Victoria, the exemption applies only to communications from the younger adolescent (Box 4). In Anna’s hypothetical case, David attending the consultation would technically trigger the GP’s duty to report (Box 3). Discussion The new duties in criminal law to report sexual offences against children are consistent with policy values in protecting children, and with bioethical principles of justice and beneficence. Requiring adults to report child sexual offences is justified by diminishing harm to individuals, and by enhancing community protection and a protective social fabric for vulnerable children.18 Sexual activity between adults and children should generally be considered abusive, due to absence of consent and presence of coercion.10 However, legislatures must ensure an appropriate balance between protecting children and youth from sexual offences, and recognising their capacity and promoting autonomy, privacy and freedom of expression.11,12 Genuinely consensual sexual activity between under‐aged minors is not abusive.10 In addition, a grey zone of cases may involve two adolescents aged almost 16, and 18. Here, where sexual activity may be genuinely consensual, ethical analysis, findings from developmental science, and clinical needs all suggest the duty should be moderated by nuanced individual consideration by clinicians (Box 3). In our view, the central concept that should inform legal principles and practice is consent, and its presence or absence in circumstances which do not involve threat, intimidation or abuse of authority. On our analysis, three conclusions seem clear. First, legislative reforms are required so that disclosures in therapeutic contexts of clearly consensual sexual activity between similar aged peers under 16 are expressly exempt from the reporting duty. This is consistent with policy animating Victoria’s law reform requiring adults to report “a serious indictable offence involving the abuse of a child”,16 and Royal Commission recommendations.17 If protected by such an exemption, clinicians consulting with adolescents who are having sex with similar aged peers can be unhindered in providing preventive health interventions including contraception for mature minors, and screening for sexually transmitted infections.18 Clinicians routinely enquire about age of sexual partners and otherwise consider risk of abuse and patient capacity when providing treatment.7 If they reasonably conclude the adolescents are consenting, confidential treatment should be provided and this is clearly incompatible with reporting to police. Such an exemption also allows clinicians to create a safe environment to encourage adolescent help‐seeking, check for other health risks,19 explore family dynamics, and connect the adolescent with parents or others to benefit wellbeing.18,19 Second, this legislative exemption could extend to clearly consensual activity between adolescents aged 15 and 18. Legal attribution of capacity to consent to sex using simple age cut‐offs is convenient, but sometimes incongruent with developmental science, lived experience and clinical scenarios.9 In situations of clearly consensual activity, a margin of error should favour patient autonomy and clinical care. This is consistent with prosecutorial guidelines and Tasmania’s similar age exemptions. Clinicians would prefer this slight extension of the exemption so they can promote health and encourage future help‐seeking. Our hypothetical patients Anna and David would be unwilling to seek future care if the GP reported David to police. Third, the different models for exempting clinicians as recipients of confidential information are complex, uncertain and unsatisfactory. Legislative reforms are required to create a clear, unified approach. Any legislature that seeks to include an exemption for confidential disclosures about abusive incidents made to medical practitioners within therapeutic contexts should enact a specific exemption, using the NSW model. This would solve difficulties ascertaining whether this constitutes a “confidential communication” or is protected by privilege. It would also solve problems in the requested non‐disclosure exemptions; for abusive incidents, application only to those over 18 is inconsistent with developmental science, which suggests Victoria’s age 16 is justifiable, and could be extended to those aged 15. This three‐pronged approach aligns with clinicians’ duty of confidentiality in codes of ethics,20 and organisational policy on sexual and reproductive health.21 National principles recognise medical practitioners’ central role in supporting sexual and reproductive health through confidential care, with youth a priority population.18,21 This medico‐legal context is increasingly complex. Our analysis has focused on adolescent peers in genuinely consensual relationships whose ages mean technically they are committing an offence, exemplified by peers aged 15 and 18 years (Box 1). We unequivocally support duties to report child sexual abuse,15,22 and do not here consider other situations where different outcomes may transpire. We also caution that where disclosures of abusive incidents may be exempt from the criminal duty, a clinician may have a separate overriding legal duty to report. For example, Victorian doctors may be exempt under s 327(7)(c) of the Crimes Act 1958 from disclosing a 10‐year‐old’s confidential disclosure of sexual assault, but must report under child protection legislation.15 Health practitioners therefore need to know their responsibilities under different laws, and need ongoing professional education to promote legal literacy. Progress towards reform may require several steps. Since legislative limitations differ, agencies representing medical practitioners could urge reform at state and territory level, informed by research and clinical experience. However, ideally, a harmonised national approach should be adopted. National medical regulatory bodies and government ministries could mobilise to support a single model law that balances the need to protect Australian children from sexual offences, while promoting adolescents’ rights to consensual sexual activity. Box 1 – Requirements of consent to sexual intercourse, by Australian states and territories Conditions for consent to sexual intercourse Jurisdiction Free and voluntary agreement Not by threat, intimidation, or abuse of authority Australian Capital Territory Crimes Act 1900, s 67 (not expressly defined) s 67(1): consent to sexual intercourse with another person is negated if that consent is caused: “(a) by the infliction of violence or force on the person, or on a third person …; or (b) by a threat to inflict violence or force on the person, or on a third person …; or (c) by a threat to inflict violence or force on, or to use extortion against, the person or another person; or (d) by a threat to publicly humiliate or disgrace, or to physically or mentally harass, the person or another person; or … (h) by the abuse by the other person of his or her position of authority over … the person” New South Wales Crimes Act 1900, s 61HE(2): “A person ‘consents’ to a sexual activity if the person freely and voluntarily agrees to the sexual activity” s 61HE(5)(c): A person does not consent to a sexual activity if the person consents “because of threats of force or terror (whether the threats are against, or the terror is instilled in, that person or any other person)” s 61HE(8): “The grounds on which it may be established that a person does not consent include … (b) if the person consents to the sexual activity because of intimidatory or coercive conduct, or other threat, that does not involve a threat of force, or (c) if the person consents to the sexual activity because of the abuse of a position of authority or trust” Northern Territory Criminal Code Act 1983, s 192(1): “consent means free and voluntary agreement” s 192(2): “Circumstances in which a person does not consent to sexual intercourse … include circumstances where: (a) the person submits because of force, fear of force, or fear of harm of any type, to himself or herself or another person” Queensland Criminal Code 1899, s 348(1): “consent means consent freely and voluntarily given by a person with the cognitive capacity to give the consent” s 348(2): “consent to an act is not freely and voluntarily given if it is obtained—(a) by force; or (b) by threat or intimidation; or (c) by fear of bodily harm; or (d) by exercise of authority …” South Australia Criminal Law Consolidation Act 1935, s 46(2): “a person consents to sexual activity if the person freely and voluntarily agrees to the sexual activity” s 46(3): a person does not freely and voluntarily agree to sexual activity if “(a) the person agrees because of (i) the application of force or an express or implied threat of the application of force or a fear of the application of force to the person or to some other person; or (ii) an express or implied threat to degrade, humiliate, disgrace or harass the person or some other person” Tasmania Criminal Code 1924, s 2A(1): “‘consent’ means free agreement” s 2A(2):”a person does not freely agree to an act if the person … (b) agrees or submits because of force, or a reasonable fear of force, to him or her or to another person; or (c) agrees or submits because of a threat of any kind against him or her or against another person; or … (e) agrees or submits because he or she is overborne by the nature or position of another person” Victoria Crimes Act 1958, s 36(1): “consent means free agreement” s 36(2): ”Circumstances in which a person does not consent to an act include, but are not limited to, the following—(a) the person submits to the act because of force or the fear of force, whether to that person or someone else; (b) the person submits to the act because of the fear of harm of any type, whether to that person or someone else” Western Australia Criminal Code Compilation Act 1913, s 319(2)(a): “consent means a consent freely and voluntarily given” s 319(2)(a): “a consent is not freely and voluntarily given if it is obtained by force, threat, intimidation, deceit, or any fraudulent means” Box 2 – Close‐in‐age defence for sex with a minor under the legal age of consent, where intercourse is consensual Jurisdiction Legislation Age of consent Express defence for intercourse with someone under the legal age of consent if similar in age, and consent is provided Australian Capital Territory Crimes Act 1900, s 55(2) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 10 or over: s 55(3)(b) New South Wales Crimes Act 1900, s 66C(3) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 14 or 15: s 80AG Northern Territory Criminal Code Act 1983, s 127(1) 16 No Queensland Criminal Code Act 1899, s 215(1) 16 No South Australia Criminal Law Consolidation Act 1935, s 49(3) 17 Yes — if accused was under 17, and child was 16: ss 49(4)(a) and (4)(b)(i) Tasmania Criminal Code Act 1924, s 124 17 Yes — age gap not more than 5 years, if child was aged at least 15: s 124(3)(a); and age gap not more than 3 years, if child was aged at least 12: s 124(3)(b) Victoria Crimes Act 1958, s 49B 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 12 or over: s 49V Western Australia Criminal Code Act 1913, s 321(2) 16 No Box 3 – Hypothetical clinical case study Anna is 15 years of age and in Year 10 at a co‐educational high school in Victoria. She has been getting good grades and has a part‐time job at a supermarket. David is 18 years of age, in Year 12 at Anna’s school, and works at the same supermarket. They have been dating for 3 months. Anna presents to her general practitioner for contraceptive advice. She has become sexually active with David and wants contraception additional to condoms. Her GP confirms Anna is a mature minor, since she understands fully the range of contraceptive options open to her, how they work, and their side effects. She has carefully considered all options with David, and has chosen a long‐acting reversible contraceptive implant. She intends to inform her mother, but she is not quite ready yet. She is certain she does not want to experience an unintentional pregnancy. Anna describes her relationship with David as very positive. She feels completely safe with him and under no coercion. She feels she could stop the relationship at any time if she wanted to, and so could he. The age of consent for sexual intercourse in Victoria is 16. Where sex involves a minor aged 12–15, no offence is committed if the other person is less than 2 years older than the minor, and the sex is consensual. Technically, David is committing a sexual offence by having sex with Anna, because he is 3 years older than her; if he was 17 there would be no offence. However, the GP is satisfied this relationship is consensual, and previously would not have reported this situation under either criminal law or child protection law. However, the criminal law on failure to disclose that commenced in Victoria in 2014 has now presented a dilemma for the GP. These laws aim to protect children from sexual abuse and require adults to report knowledge of a sexual offence with a child under 16 years to police. Anna has not expressly stated to the GP that she does not want the situation reported to police, since it has not occurred to her that anything wrong has happened. The GP studies the government website on the new laws to understand what she should do. She is relieved to learn health practitioners are exempt from the criminal law duty to report if they are told about the offence in the course of a confidential consultation. However, because of other legal definitions (Box 4), this exemption only applies if consulting exclusively with the person against whom the offence has been committed. The next day, Anna and David consult the GP together for a baseline sexually transmitted infection screen. The GP was happy to see them, but was perplexed that the exemption did not apply if consulting with the offender, in this case David. She was very reluctant to call the police about David and Anna, due to her knowledge about the consensual nature of their relationship, and their responsible behaviour in obtaining contraception. The GP also understands that other adults who know about the situation, such as Anna’s and David’s parents and school teachers, would appear to be required to report by the criminal law duty, since no clear exemptions apply to them. Box 4 – Health Practitioner Regulation National Law: definitions and application In Victoria, a “confidential communication” is “a communication, whether oral or written, made in confidence by a person against whom a sexual offence has been, or is alleged to have been committed to a registered medical practitioner or counsellor in the course of the relationship of medical practitioner and patient or counsellor and client”: Evidence (Miscellaneous Provisions) Act 1958, s 32B. Under the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5, “health practitioner means an individual who practises a health profession”. A “registered health practitioner means an individual who (a) is registered under this Law to practise a health profession, other than as a student; or (b) holds non‐practising registration under this Law in a health profession”. A “health profession” is defined to include a list of 15 professions (including recognised specialties in these), and most relevantly here includes the following professions: medical, nursing, pharmacy, and psychology. In Victoria, a “registered medical practitioner” under the Health Practitioner Regulation National Law is defined through the application of the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5. Victoria incorporated the Queensland Act into Victorian law, through the Health Practitioner Regulation National Law (Victoria) Act 2009, s 4 (Application of Health Practitioner Regulation National Law). The Health Practitioner Regulation National Law is also incorporated into other jurisdictions’ laws: Health Practitioner Regulation National Law (Tasmania) Act 2010, s 4; Health Practitioner Regulation (Adoption of National Law) Act 2009 (NSW), s 4; Health Practitioner Regulation National Law (ACT) Act 2010, s 6.

Ben Mathews · Lena A Sanci

Annual audits of practice, national guidelines, specialist diabetes care teams, and increased patient participation are all needed

Jeffrey D Zajac · Sofianos Andrikopoulos

More research is needed to ensure safe and unimpeded access for eligible applicants and to inform practice

Cameron J McLaren · Greg Mewett

A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

Adrian J Dunlop · Buddhima Lokuge · Nicholas Lintzeris

Objectives: To assess the quality of care for patients with diabetes in Queensland hospitals, including blood glucose control, rates of hospital‐acquired harm, the incidence of insulin prescription and management errors, and appropriate foot and peri‐operative care. Design, setting: Cross‐sectional audit of 27 public hospitals in Queensland: four of five tertiary/quaternary referral centres, four of seven large regional or outer metropolitan hospitals, seven of 13 smaller outer metropolitan or small regional hospitals, and 12 of 88 hospitals in rural or remote locations. Participants: 850 adult inpatients with diabetes mellitus in medical, surgical, mental health, high dependency, or intensive care wards. Results: Twenty‐seven of 115 public hospitals that admit acute inpatients participated in the audit, including 4175 of 6652 eligible acute hospital beds in Queensland. A total of 1003 patients had diabetes (24%), and data were collected for 850 (85%). Their mean age was 65.9 years (SD, 15.1 years), 357 were women (42%), and their mean HbA1c level was 66 mmol/mol (SD, 26 mmol/mol). Rates of good diabetes days (appropriate monitoring, no more than one blood glucose measurement greater than 10 mmol/L, and none below 5 mmol/L) were low in patients with type 1 diabetes (22.1 per 100 patient‐days) or type 2 diabetes treated with insulin (40.1 per 100 patient‐days); hypoglycaemia rates were high for patients with type 1 diabetes mellitus (24.1 episodes per 100 patient‐days). One or more medication errors were identified for 201 patients (32%), including insulin prescribing errors for 127 patients (39%). Four patients with type 1 diabetes experienced diabetic ketoacidosis in hospital (8%); 121 patients (14%) met the criteria for review by a specialist diabetes team but were not reviewed by any diabetes specialist (medical, nursing, allied health). Conclusions: We identified several deficits in inpatient diabetes management in Queensland, including high rates of medication error and hospital‐acquired harm and low rates of appropriate glycaemic control, particularly for patients treated with insulin. These deficits require attention, and ongoing evaluation of outcomes is necessary.

Peter Donovan · Jade Eccles-Smith · Nicola Hinton · Clare Cutmore · Kerry Porter · Jennifer Abel · Lee Allam · Alexis Dermedgoglou · Gaurav Puri

Objectives: To investigate the perspectives of doctors involved with voluntary assisted dying in Victoria regarding the Voluntary Assisted Dying Act 2017 (Vic) and its operation. Design, setting, participants: Qualitative study; semi‐structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation (commenced 19 June 2019). Doctors were interviewed during April‒July 2020. Results: Three major themes related to problems during the first year of operation of the Act were identified: the statutory prohibition of health professionals initiating discussions with their patients about voluntary assisted dying; the Department of Health and Human Services guidance requirement that all doctor‒patient, doctor‒pharmacist, and pharmacist‒patient interactions be face‐to‐face; and aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service. Conclusions: Doctors reported only limited concerns about the Victorian voluntary assisted dying legislation, but have had some problems with its operation, including implications for the accessibility of voluntary assisted dying to eligible patients. While legislative change may resolve some of these concerns, most can be ameliorated by improving the processes and systems.

Lindy Willmott · Ben P White · Marcus Sellars · Patsy M Yates

Objective: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. Design: Retrospective data linkage study. Setting, participants: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 ‒ June 2014 and were alive six months after entry. Main outcome measures: Inverse probability of treatment‐weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. Results: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4‒1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4‒1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59‒3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18‒2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25‒2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98‒1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. Conclusions: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Heidi J Welberry · Louisa R Jorm · Andrea L Schaffer · Sebastiano Barbieri · Benjumin Hsu · Mark F Harris · John Hall · Henry Brodaty

The need to treat chronic pain and the increasing number of patients requiring opioid therapy are among the factors that have led to prescription opioid‐related harm. Several professional society guidelines aim to reduce the frequency of opioid‐related problems by modifying prescriber behaviour.1,2 We analysed Monitoring of Drugs of Dependence System (MODDS) data for adult Queensland residents (18 years or older) for whom opioids were dispensed during 1 January 1997 ‒ 31 December 2018. Our aim was to determine the most frequently prescribed doses of opioids, and to examine associations between the mean number of prescribers per patient and the opioid doses dispensed. The database included data for 228 861 opioid prescribers during the study period and 18 798 942 dispensed opioid prescriptions. We undertook multivariate mixed effects Poisson regression, with random intercept by patient identification to account for within‐patient correlations and between‐patient characteristics. We adjusted for socio‐economic status of patient residence (by postcode),3 as an association between lower socio‐economic status and greater opioid prescribing has been reported.4 We also adjusted our analysis for duration of opioid use, dose in oral morphine milligram equivalents per day (MME/day), and opioid formulation, as in our previous studies.5,6 The study was approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee (HREC/17/QRBW/669), the University of Queensland Human Research Ethics Committee (2018000623/HREC/QRBW/669), and by the Department of Health under the Public Health Act 2005 (Qld) (RD007970). The number of patients for whom opioids were dispensed increased from 28 299 in 1997 to 322 307 in 2018; the number of Queensland medical practitioners who prescribed opioids increased from 4537 to 20 226 (online Supporting Information, table). The proportion of opioid prescribers who prescribed opioids at doses of 50 to less than 100 MME/day peaked in 2003 (813 of 5530, 14.7%), as did the proportion prescribing 100 MME/day or more (1077, 19.5%), before declining in 2018 to 1294 (6.4%) and 1064 of 22 941 (5.3%) respectively (Box 1, A; Supporting Information, figure). During 1997‒2018, 1 916 842 people (67.8% of people dispensed opioids) were dispensed doses of less than 20 MME/day, 624 114 were dispensed 20 to less than 50 MME/day (22.1%), 159 448 were dispensed 50 to less than 100 MME/day (5.6%), and 127 323 were dispensed 100 MME/day or more (4.5%) (Box 1, B). For modified release opioids, the largest proportions of prescribers and patients were for the 20 to less than 50 MME/day dose category (Box 1, C, D). The mean number of prescribers per patient per year increased with the dose of opioids dispensed (v < 20 MME/day: 20 to < 50 MME/day, incidence rate ratio [IRR],1.04; 95% confidence interval [CI], 1.03‒1.04; 50 to < 100 MME/day, IRR, 1.09; 95% CI, 1.08‒1.09; ≥ 100 MME/day, IRR, 1.22; 95% CI, 1.21‒1.22) (Box 2). However, the mean number of prescribers per patient per year increased as the duration of opioid dispensing decreased (patients dispensed opioids for one month v for 7‒12 months: IRR, 1.36; 95% CI, 1.35‒1.36). This finding is consistent with a report that people using opioids for shorter periods more frequently visit multiple prescribers.4,5 Our findings indicate that most Queensland medical practitioners prescribe lower opioid doses, and that the proportion prescribing lower doses has increased since 2004. The proportion of people dispensed doses of opioids associated with increased risk of accidental overdose (from 50 MME/day) was small and has declined over time. Box 1 – Proportions of patients prescribed opioid medications and of prescribers, by opioid dose prescribed* * Opioids included were morphine, oxycodone, hydromorphone, tapentadol, fentanyl, buprenorphine, and codeine; methadone was excluded because we could not distinguish between prescribing for pain management and opioid replacement therapy. All formulations except lozenges, suppositories and parenteral formulations were included, apart from tablet and sublingual buprenorphine formulations (used to treat gastrointestinal problems and opiate dependence) and fentanyl (approved for palliative care). For complete inclusion and exclusion criteria, see Supplementary Material 3 in reference 6. Box 2 – Mean numbers of prescribers per patient per year, by daily opioid dose, duration of dispensing, and socio‐economic status table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Mean prescribers per patient per year (95% CI) Incidence rate ratio (95% CI) Unadjusted Adjusted* Prescribed dose (MME/day) < 20 1.62 (1.61–1.62) 1 1 20 to < 50 1.76 (1.75–1.76) 1.08 (1.08–1.09) 1.04 (1.03–1.04) 50 to < 100 2.05 (2.04–2.05) 1.26 (1.26–1.27) 1.09 (1.08–1.09) ≥ 100 2.90 (2.89–2.92) 1.79 (1.79–1.80) 1.22 (1.21–1.22) Duration of use (months) ≤ 1 1.81 (1.81–1.82) 1.41 (1.41–1.42) 1.36 (1.35–1.36) 2‒3 1.50 (1.49–1.50) 1.17 (1.17–1.18) 1.16 (1.16–1.17) 4‒6 1.40 (1.39–1.40) 1.09 (1.09–1.10) 1.09 (1.09–1.10) 7‒12 1.28 (1.27–1.28) 1 1 Socio‐economic status (quintile)† 1 (lowest) 1.92 (1.92–1.93) 1.11 (1.11–1.12) 1.07 (1.07–1.08) 2 1.93 (1.92–1.93) 1.11 (1.11–1.12) 1.05 (1.05–1.06) 3 1.80 (1.79–1.80) 1.04 (1.04–1.05) 1.03 (1.02–1.03) 4 1.78 (1.78–1.79) 1.03 (1.03–1.04) 1.01 (1.01–1.02) 5 (highest) 1.72 (1.71–1.72) 1 1 Formulation Immediate release 1.66 (1.65–1.66) 1 1 Modified release 1.97 (1.97–1.98) 1.19 (1.18–1.19) 0.98 (0.99–1.00) MME = morphine milligram equivalent; CI = confidence interval. * Multivariate mixed effects Poisson regression adjusted for socio‐economic status, duration of opioid dispensing, opioid dose, and opioid formulation. † Socio‐Economic Indexes for Areas (SEIFA Index of Relative Socio‐Economic Advantage and Disadvantage (IRSAD).3

Adeleke D Adewumi · Joemer C. Maravilla · Rosa Alati · Samantha A Hollingworth · Xuelei Hu · Bill Loveday · Jason Connor

To the Editor: A 35‐year‐old man born in Dire Dawa, Ethiopia, with childhood exposure to swimming in rivers, migrated to Australia 18 years ago. He presented with recurrent gastrointestinal bleeding. His index gastroscopy revealed portal hypertensive gastropathy and large oesophageal varices with high risk stigmata of recent bleeding requiring banding. Abdominal ultrasonography and transient elastography excluded liver cirrhosis. Six weeks later, he re‐presented with recurrent severe haematemesis associated with dark maroon rectal bleeding. Repeat urgent gastroscopy and flexi‐sigmoidoscopy revealed oesophageal varices without active bleeding. On sigmoidoscopy, a large amount of dark blood was seen, presumed to be related to rapid transit from recent oesophageal variceal bleeding. In the next 48 hours, a repeat colonoscopy was performed. Colonoscopy identified yellowish nodules throughout the colon with diffuse telangiectasia (Box, A and B). Mucosa was oedematous and friable. Aphthous ulcers were seen in the transverse colon and biopsies were obtained. No polyps or focal source of colonic bleeding were evident. Histopathology confirmed the presence of cystic ova resembling Schistosoma in the lamina propria immediately adjacent to crypts. Although classical granuloma formation was absent, aggregation of eosinophils was seen around a ruptured ovum (Box, C and D). Indirect assay via serology testing was positive for Schistosoma mansoni antibody (titre of 1:640). His eosinophil count was normal and stool microscopy was negative. He was treated with praziquantel. Four months later, a follow‐up gastroscopy revealed stable appearance of grade 1 oesophageal varices without high risk features. Routine variceal surveillance had been organised but not further colonoscopies. Schistosomiasis affects over 200 million people worldwide but is not acquired in Australia. In a national survey in Ethiopia, 37.3 million individuals were living in endemic areas.1 Schistosoma mansoni is the commonest species to cause intestinal and hepatic schistosomiasis. In the 2016 national census, there were 11 795 people in Australia who were born in Ethiopia, 64.3% (7584) of whom were Australian citizens.2 Most screening data for schistosomiasis in Australia are based on African refugees, with 37% in Newcastle, 38% in Hobart and 12% in Melbourne.3 Despite anecdotal knowledge, there are no published cases of non‐cirrhotic portal hypertension related to schistosomiasis in Australia. As a multiracial country with high immigration and tourism, increased recognition in Australia is paramount. Box – Colonoscopy showing widespread yellowish nodules (arrows) with oedematous and friable mucosa (A) and diffuse telangiectasia (B); and histopathology showing aggregation of eosinophils surrounding a Schistosoma ovum(C) and a cross‐sectional image of a Schistosoma ovum (D)

Julia Lim · Shweta Sharma · Damian Dowling

To the Editor: We read with interest the article by Kault,1 who carried out an analysis on superspreaders, asymptomatic cases, and coronavirus disease 2019 (COVID‐19) elimination. Although all efforts made for preventing or containing the COVID‐19 pandemic are certainly welcome, we raise doubts on some basic aspects used for constructing the prediction model and which do not seem to be evidence‐based. In the risk model of COVID‐19 re‐emergence after release of restrictive measures (eg, lockdowns), Kault made some erroneous assumptions, including the fact that asymptomatic subjects may be as infectious as symptomatic patients with COVID‐19.1 This hypothesis seems to be contradicted by several lines of evidence. First, a meta‐analysis published in 2020 concluded that the rate of asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is 35% lower compared with COVID‐19 patients with symptomatic illness.2 This has also been clearly explained in a seminal study showing that the viral load is the highest in concomitance with symptoms onset, so that the infectiousness of pre‐symptomatic or asymptomatic individuals is probably low.3 Notably, the impact of pre‐symptomatic SARS‐CoV‐2 transmission seems also rather limited, whereby the secondary attack rate was found to account for only 15% of all secondary COVID‐19 cases.4 A second aspect that needs to be highlighted is that presuming that 50% of SARS‐CoV‐2‐positive patients are asymptomatic may also be formally incorrect. Beside the fact that the asymptomatic SARS‐CoV‐2‐positive rate varies greatly depending on many genetic, demographic (ie, age, sex and ethnic origin) and even clinical (eg, time course of disease, comorbidities) variables, an analysis in the official database of the Italian National Institute of Health reveals, for example, that the rate of asymptomatic subjects with SARS‐CoV‐2 infection approximates 70%.5 Combined with lower infectiousness, the high prevalence of asymptomatic subjects bearing SARS‐CoV‐2 infection after release of restrictive practices (eg, lifting of lockdowns) would persuade us to conclude that the possible impact of asymptomatic superspreaders on SARS‐CoV‐2 transmission would be low and perhaps insufficient to influence or guide future policies aimed at restricting individual freedom.

Camilla Mattiuzzi · Giuseppe Lippi

In reply

David Kault

To the Editor: Recruitment and retention of a sustainable rural health workforce was one of four issues highlighted by Osborne in a recent MJA supplement.1 Chapter 4 of the Supplement describes a need for longitudinal methods to evaluate recruitment and retention of nursing and allied health professionals, noting challenges around scale and links to policy.2 Comparative efforts examining the medical workforce in Australia are more advanced (eg, the Medical Schools Outcomes Database). Chapter 5 concludes there is a need for a longitudinal, linked database to address rural workforce planning that utilises public data sources, noting medicine was covered by all primary data sources identified, yet only three covered all health professions.3 The Nursing and Allied Health Graduate Outcome Tracking (NAHGOT) study is a research collaboration between the University of Newcastle, Monash University and Deakin University that addresses issues of scale and relevance to national health workforce policy. NAHGOT links Australian Health Practitioner Regulation Agency practice location data (the outcome) with university administrative records (explanatory variables including placement location and duration), and is complemented by the national Student Experience and Graduate Outcomes Surveys. Further complementing the NAHGOT database are the publicly available Socio‐Economic Indexes for Areas at varying spatial resolutions (eg, Statistical Areas Level 1 to Level 4), a general measure of spatial access (Australian Statistical Geography Standard — Remoteness Areas), and a workforce specific model used to define Distribution Priority Areas (Modified Monash Model). Across the nursing and allied health disciplines offered by the three universities, data from a new cohort of about 2000 first year students are captured annually and securely stored in a central, de‐identified repository. Database access is currently restricted to participating institutions, with the longer term intent to permit external data extractions based upon predefined study protocols through a formal process. To our knowledge, NAHGOT is the largest tracking study of this type and growing, with three other universities soon to join the collaboration, enabling expansion into Queensland and South Australia. All participating universities are funded by the Rural Health Multidisciplinary Training Program, with the study design reflecting the objectives of the federal Department of Health. Universities are the logical choice to undertake tracking of graduate outcomes at scale. Unlike other data sources, universities hold admission and professional placement data not available elsewhere. The protocol will soon be available4 and the first peer reviewed publications from NAHGOT have now been published,5,6 and as the project expands it is anticipated it will become a major contributor to workforce planning and augment established efforts in medicine.

Vincent L Versace · Tony Smith · Keith Sutton

In reply

Marianne H Gillam · Martin Jones · Esther May

To the Editor: Victoria introduced voluntary assisted dying in June 2019, historic legislation which aimed to enable terminally ill people in limited circumstances to end their life with autonomy, compassion and support. The Voluntary Assisted Dying Act 20171 is considered the most conservative and safe legislation in the world, with 68 safeguards. We compared recent Victorian reporting data2,3 with a 12‐month period of data on Oregon’s Death with Dignity Act (1997),4 as the jurisdictions have similar population sizes and there is no comparable jurisdiction currently operating in Australia. To access voluntary assisted dying in Victoria a person must: have an incurable and advanced disease, illness or medical condition that is expected to cause death within 6 months (or within 12 months for a neurodegenerative condition); be experiencing suffering, which the person considers intolerable; have decision‐making capacity in relation to voluntary assisted dying; be an adult, aged 18 years or older; and be an Australian citizen or permanent resident who has lived in Victoria for at least the past 12 months. Eligibility requirements for Oregonians are comparable; however, there is no requirement to demonstrate intolerable suffering. Based on a total number of 46 581 deaths in Victoria during the 2019–2020 period, 0.3% of deaths can be attributed to voluntary assisted dying.5 In both Victoria and Oregon, the most frequently reported reasons for requesting voluntary assisted dying and dying with dignity were loss of autonomy and losing control of body functions; additionally, loss of dignity and being unable to engage in activities that make life enjoyable were also cited. Data show that: Victorian applicants were aged between 32 and 100 years, with an average age of 71 years.2,3 In comparison, the average age in Oregon was 74 years, with a range of applicants from 18 to over 85 years.4 In Victoria, 44% of applicants were female, 55% were male and 1% selected “self‐described” as their gender,2,3 comparable to Oregon (41% female and 59% male).4 Between 19 June 2019 and 30 June 2020, 231 permits were issued. Of these, 104 (45%) self‐administered the medication, while another 20 (9%) had the medication administered by a medical practitioner (Box).2,3 Oregon data from 2019 (population, 4.2 million) revealed that 290 applicants were prescribed medication, with 150 (59%) self‐administering;4 in Victoria (population, 6.3 million), 54% self‐administered, while another 61 (21%) did not take the medication and died of other causes. In addition to the first 12 months of Victorian data, we also included the cumulative totals to February 2021 (Box). The Victorian Act requires three requests be made to a registered medical practitioner for an individual to access voluntary assisted dying. Medical practitioners can apply for either a self‐administration or practitioner administration permit at any one time. Time from first to last request occurred within 11 days for 25% of applicants and 19 days for 50% of applicants.2 Voluntary assisted dying and dying with dignity represent an option for individuals to choose the manner and timing of their death during the terminal phase of illness. Continued community awareness and conversations about end of life options are essential to ensuring that voluntary assisted dying is available to eligible Victorians who seek access. Box – Victorian voluntary assisted dying data snapshot4,5 Total Stage Status 19 June 2019–30 June 2020 To February 2021 Eligibility First assessment by coordinating medical practitioner Eligible 341 562 Ineligible 7 19 Second assessment by consulting medical practitioner Eligible 297 483 Ineligible 4 8 Permit applications Self‐administration permit Issued 201 350 Not issued 32 44 Practitioner administration permit Issued 30 55 Not issued 9 16 Withdrawn: case withdrawn from portal by medical practitioner or upon notification of death of the applicant 134 239 Medications dispensed For self‐administration 154 281 Confirmed deaths Medication administered Self‐administered 104 184 Administered by practitioner 20 40

Kate Furness · Donna Markham · Tamica Sturgess · Margaret O’Connor

To the Editor: The Medical Research Future Fund (MRFF) should be a policy triumph for the Australian Government, tackling unmet clinical needs through transformative research that saves lives, creates jobs and strengthens the industry.1 However, to deliver these objectives, medical research findings must be translated from the laboratory and library to achieve impact on the clinic, community and companies. The capacity for efficient health research translation has been limited in Australia.2 The MRFF provided $20 million per year, finishing in 2021, to pump‐prime Australia’s ten health research translation centres designated by the National Health and Medical Research Council, in which we work. The Translation Centres bring health services and consumers together with health researchers from universities and medical research institutes. Distributed across the nation, the Centres have come together to form the Australian Health Research Alliance (AHRA), providing a “go to” destination for those seeking expertise in health research translation.3 We want to see that research‐ and translation‐trained practitioners in medicine, nursing, allied health disciplines, clinical laboratories, pharmacy, health informatics and other frontline services have time stably funded to deploy their skills in a role we describe as “research translators”.4 Alongside conventional health care duties, such staff will have dedicated time to engage consumers, recruit participants to clinical research, partner with industry, prove the relevance of research to their service, promote best evidenced practice, and champion the adoption of innovation. While overseas governments invest heavily in such roles, funding time for frontline clinical staff to deliver research and translation alongside their clinical work, Australia does not. For example, the National Institute of Health Research in the United Kingdom commits approximately $20 per citizen per year, with an impressive impact on lives saved, jobs created and industry invigorated.5 Australia should address this translational workforce gap or risk failure to achieve full beneficial impact from the MRFF. About $65 million per year (about 10% of the MRFF investment income) would support a cadre of research translators broadly proportional to the provision from comparable research budgets overseas, with AHRA’s Centres best placed to provide efficient coordination. Thus, the MRFF would be powered for success by investing in research translators through AHRA, ensuring the triumph of an exciting new policy that promises benefit to all Australians.

John Savill · Christopher Levi · Gary Geelhoed