Volume 215 Issue 7

Evidence supports the establishment of a national TP-IAT program, delivered at sites with a concentration of expertise and experience

Jessica Eldredge · Michael R Couper · David J Moore · Sanjeev Khurana · John WC Chen · Jennifer J Couper · Christopher J Drogemuller · Toni Radford · Thomas W Kay · Tom Loudovaris · Michael Wilks · Patrick T Coates · Richard TL Couper

With rising expenditure, growing chronic disease burden, and widening inequalities, the health system is in urgent need of redesign

Elizabeth Koff · Susan Pearce · David P Peiris

The health reform imperative is clear; it now requires national courage and leadership to implement it

Claire L Jackson · Diana O’Halloran

It is important to establish a research culture that is embraced by the community, rather than viewed with distrust

Ella Kris · Hylda Wapau · Allison Hempenstall

What Australia can learn from overseas guidelines

Katherine Sewell · Tamara Tse · Geoffrey A Donnan · Leeanne M Carey

Public willingness to pay higher taxes is an important signal, but additional financial pillars are needed

Julie Ratcliffe · Jyoti Khadka · Sheela Kumaran · Billingsley Kaambwa

A 57-year-old man presented with left facial droop and dysarthria due to a multiterritory ischaemic stroke affecting the right posterior and middle cerebral arteries

Jessica V Yao · Subodh B Joshi · John G Morgan · Melissa GY Lee

A 15-year-old girl presented with a 4-day history of dysuria, urinary frequency and back pain followed by 2 days of vomiting and rigors

Betty S Chan · Alexander Kiss · Nathan McIntosh · Vicky Sheppeard · Andrew H Dawson

Scaling up the treatment of alcohol problems will lead to considerable health benefit across the nation

Paul S Haber · Benjamin C Riordan · Kirsten C Morley

Consistent national mental health policy and planning are needed to adequately care for their special needs

John Allan

A national education program would facilitate achieving the full potential of highly effective curative therapies

Paul J Clark

Quarantine systems required to manage increasing proportions of returning travellers infected with SARS-CoV-2 need improving

Leah Grout · Ameera Katar · Driss Ait Ouakrim · Jennifer A Summers · Amanda Kvalsvig · Michael G Baker · Tony Blakely · Nick Wilson

Objectives: To describe the population characteristics of people with intellectual disability in New South Wales; to quantify and compare public mental health service use and costs for people with and without intellectual disability in NSW during 2014‒15. Design: Retrospective cohort data linkage analysis. Setting, participants: People using publicly funded in‐ or outpatient (admitted or non‐admitted) mental health services in NSW, 2014‒15. Main outcome measures: Numbers of bed days (inpatient mental health services), and treatment days (ambulatory mental health); costs of publicly funded mental health services. Results: People with intellectual disability comprised 1.1% of the NSW population, but 6.3% of people who used public mental health services; 12% of public mental health costs during 2014–15 were for people with intellectual disability. Compared with metropolitan local health districts (LHDs), overall public mental health service costs were lower for rural and regional LHDs (adjusted incidence rate ratio [aIRR], 0.8; 95% CI, 0.8–0.9) and higher for specialty networks (aIRR, 1.2; 95% CI, 1.1–1.3). Per person costs for people with intellectual disability were higher than for those without intellectual disability (aIRR, 2.6; 95% CI, 2.2–3.0). Conclusion: People with intellectual disability use public mental health services to a greater degree than other people. They should be explicitly considered by all tiers of mental health policy and service planning in Australia. Population health planning for the needs of people with disabilities would be assisted by including disability identifiers in all health administrative data sets.

Preeyaporn Srasuebkul · Rachael Cvejic · Theresa Heintze · Simone Reppermund · Julian N Trollor

GPs are gaining confidence in prescribing DAA therapy, an important foundation for further enhancing access to treatment

Fergus Stafford · Gregory J Dore · Shawn Clackett · Marianne Martinello · Gail V Matthews · Jason Grebely · Anne C Balcomb · Behzad Hajarizadeh

To the Editor: I read with interest the consensus statement on hepatocellular carcinoma (HCC)1 and wonder why it overlooked that smoking is a major cause. Smoking is an independent and dose‐related contributing factor for HCC (relative risk, 1.51; 95% CI, 1.37–1.67) around the world.2,3 In a large European cohort, the population‐attributable fraction — the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario — for tobacco use in HCC was 48 %, more than twice the population‐attributable fraction of the second most common risk factor: hepatitis C (21%).4 In France, where smoking prevalence is high and roughly twice that in Australia, tobacco, viral hepatitis and alcohol contribute to 33%, 31% and 26% respectively of HCC cases.5 The issue is not only about prevention but also about care, as smoking cessation is an important factor in cancer outcomes (ie, treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life). Lastly, only nine out of 31 recommendations in the consensus statement are graded “A1” and none are among the four related to surveillance.

Alain Braillon

In reply

John S Lubel · Stuart K Roberts · Simone I Strasser · Nick Shackel

To the Editor: The extension of alcohol brands to non‐alcohol products has been part of the marketing strategy of some alcohol companies on several occasions.1 Recent examples highlight that this marketing tactic warrants further research and policy attention in Australia. Following the release of a limited‐edition Bundaberg Rum‐branded Ice Break (iced coffee) in Queensland in 2019, the product was rolled out nationally in supermarkets and petrol stations in October 2020. This follows similar examples of alcohol‐branded chocolates, zero‐alcohol beverages, and fragrances. The alcohol advertising code of practice in Australia, administered by the industry‐managed Alcohol Beverages Advertising Code (ABAC) Scheme, applies to alcohol brand extensions; however, determinations suggest that the code does not restrict alcohol companies from applying their brands to a variety of non‐alcohol products. In 2019 and 2020, the ABAC Panel reviewed nine complaints about brand extensions, including the rum‐branded iced coffee (Box).2 A common theme raised by complainants was concern about children and young people’s exposure. In almost all cases, the ABAC Panel determined that the alcohol‐branded products or associated marketing would not have strong or evident appeal to minors. Most of the complaints were dismissed. Extending well known alcohol brands to non‐alcohol products provides companies with the opportunity to expose new audiences to their brands, including children and adolescents. While some extensions may not have overt appeal to children, the display of alcohol‐branded products in supermarkets and other retail outlets means children will be exposed to the marketing and may develop connections with the brands.3 The use of brand extensions has also been a strategy of the tobacco industry.1Based on the available determinations, the ABAC Scheme permits alcohol brands to be used on a wide variety of products that are not typically related to alcohol. The inadequate controls on brand extensions are consistent with reviews that have concluded that the ABAC Scheme does little to protect young people from exposure to alcohol marketing.4,5 Efforts to encourage governments to hold the alcohol industry to a higher standard in their marketing would be aided by further attention, including research attention, to the use of brand extensions by alcohol companies. Box – Alcohol Beverages Advertising Code (ABAC) Scheme determinations about alcohol brand extensions published in 2019 and 20202 Product Summary of complaint Outcome and summary of ABAC Panel comments VB‐branded Volleys (ABAC determination No. 185/20) Alcohol promotion via a shoe brand will expose children to the marketing and glorify alcohol use. Upheld in part. The VB‐branded shoes are not merchandise primarily used by young people so the product itself does not breach the ABAC Code. However, one of the associated online promotions featuring a person skateboarding while wearing the VB‐branded shoes would have strong appeal to young people. VB‐branded fragrance sold by the national chemist chain Chemist Warehouse (ABAC determination No. 124/20) The VB‐branded fragrance was marketed as an appropriate gift for Father’s Day, appealing to children and young people. The promotion seen outside a chemist included an image of a child hugging a man next to the words “#1 for Father’s Day”. Children and young people visiting the chemist would be exposed to the VB brand. Dismissed. The VB branding on the fragrance and the poster seen outside the chemist would not strongly appeal to young people, and there are no rules restricting the placement of alcohol ads in shopping centres. Heineken 0.0 television ad (ABAC determination No. 99/20) The ad promoted the product as alcohol‐free when it may not be completely alcohol‐free, and children may drink the product believing it is not alcoholic. Dismissed. The ad shows adults in an adult situation, and would not have particular attractiveness to minors beyond the appeal it has for adults. Bundaberg Rum‐branded Paul’s egg nog (ABAC determination No. 118/19) Egg nog is a flavoured milk, which is a soft drink that appeals to young people. The placement of Bundaberg Rum’s brand on the egg nog could be seen by young people. Dismissed. While flavoured milk such as chocolate milk might appeal to young people, egg nog is not considered a drink which would particularly appeal to young people. The packaging is mature and traditional and does not have features that would appeal to young people. Bundaberg Rum‐branded Ice Break drink (ABAC determination No. 82/19) The iced coffee promoted Bundaberg Rum and encouraged young people’s exposure to alcohol products and brands. Dismissed. Iced coffee as a product does not strongly or evidently appeal to young people. The product label is mature and does not contain images likely to appeal to young people. Heineken 0.0 bus stop ad (ABAC determination No. 67/19) It was not clear from the ad that the product was alcohol‐free, and it suggested that people can drink Heineken beer before driving, conflicting with anti‐drink‐driving education. Upheld. The overall impression created by the ad was positioning a Heineken product, which would be assumed to be a type of alcoholic beer, with the consumption of the product by a driver of a motor vehicle. Jack Daniels‐branded barbeque sauce and barbeque tools sold at the department store Big W (ABAC determination No. 59/19) Children would be exposed to the alcohol‐branded products being promoted in connection with Father’s Day. Dismissed. The branded barbeque products do not feature any eye‐catching designs or themes that would appeal to children or young people. Carlton Zero radio ad (ABAC determination No. 44/19) The ad referred to a “beer you can drink anywhere” and provided examples of places where it is inappropriate or irresponsible to consume alcohol, and the ad was broadcast at 12 pm on a Sunday, when children and young people are likely to be listening to the radio. Dismissed. A reasonable person would not take the ad as promoting the use of alcohol in unsafe circumstances. The timing of the broadcast was consistent with the requirements of the ABAC placement rules. Carlton Zero television ad (ABAC determination No. 35/19) Carlton Zero was marketed as a light lunch drink and could easily be misinterpreted as a soft drink. Dismissed. The ABAC definition of “strong and evident appeal to minors” refers to “confusion with a soft drink” as part of an example of how the standard might be breached. The ad taken as a whole did not create a message which could be said to be appealing to minors.

Hannah Pierce · Julia Stafford

To the Editor: A significant driver of research waste is the incentive to do research for career progression, rather than for its relevance and patient impact, especially when volume is rewarded over quality.1 We previously found that most specialty training colleges mandate that trainees conduct research, often without requiring research training and appropriate supervision. The focus tends to be on completing projects and leading research, rather than on learning fundamental research principles.2 We also wanted to understand how these incentives are built into the selection process for specialty training programs before the training even begins. In 2020, we reviewed the research‐related selection criteria on publicly available documents and websites for the training programs of 63 Australian and New Zealand specialty colleges and their subspecialty divisions. These were categorised as mandatory or encouraged; for those that used a points‐based system to grade the application, we extracted the proportion that research was worth to the overall application. While no colleges stated that research was a mandatory requirement to apply to a training program, 46 encouraged research on the prospective trainee’s application and 12 used a points‐based system to quantify their research activities (Box). Only five did not mention research. Of the 12 colleges using a points‐based system, 11 allocated points only to leading research — where the application specifically states that the applicant must be first or second author on journal articles, primary presenter at conferences, or take a leadership role in research — nine of which required this research to be conducted in the previous 4–5 years. Ten made some reference to quality, although these were often vague or generic (Box). Research was worth a median of 25% of the curriculum vitae (CV), and 7% of the overall application. This represents a numerically small but critical proportion of the overall application, since research is often used to differentiate candidates, despite number of publications at training entry being negatively correlated with clinical performance.3 As put by Doug Altman, “The length of a list of publications is a dubious indicator of ability to do good research; its relevance to the ability to be a good doctor is even more obscure”.4 No colleges allocated points for research utilisation, research training, or participation in large research teams. It appears to be far more advantageous for applicants to complete several small, low impact projects within a short time frame as first author than a single well designed randomised controlled trial as middle author. This focus on leading research leaves junior doctors vulnerable to poor quality research experiences and outputs without structured guidance and supervision.5 The current selection criteria for college training programs encourage high volume, CV‐padding research with little regard for quality or value‐adding to their field. The value of using or participating in research is apparently ignored, reducing incentives for doctors to learn good research practices and progressively acquire research skills. We posit that this is contributing to research waste. Box – Research selection criteria for applications to Australian and New Zealand medical specialty college training programs Research selection criteria Colleges n (%) Total number of colleges 63 Colleges with publicly available application documents 61/63 (97%) Mandatory 0/63 (0%) Encouraged 46/63 (73%) Encouraged with points 12/63 (19%) Authorship priority* 11/12 (92%) Research topic must be specialty‐specific 5/12 (42%) Time limit (median) 9/12 (75%)† Quality 10/12‡ (83%) Not mentioned 5/63 (8%) * First or second authorship on journal articles or primary presenter at conferences. † One college had a limit of 4 years; all others had a limit of 5 years. ‡ Quality — any mention, including peer‐reviewed, impact factor of journals, and fewer points for case reports.

Caitlyn Withers · Christy Noble · Caitlin Brandenburg · Paul P Glasziou · Paulina Stehlik

Med J Aust 2021; 215 (7 Suppl).