Volume 217 Issue 4

Without data on access to, or quality of, the care for people with disability, it is impossible to determine drivers of health inequities, and to develop evidence-informed policies to improve care and track progress towards reducing health inequities

Jodie Bailie · Nicola Fortune · Julie Gordon · Richard C Madden · Gwynnyth Llewellyn

Fostering engagement among older patients and families and creating opportunities for decision making about medications are crucial for improved safety and quality across transitions of care

Elizabeth Manias · Carmel Hughes · Robyn E Woodward‐Kron · Christine M Jorm · Guncag Ozavci · Tracey K Bucknall

Assessing a person’s eligibility for VAD is difficult because prognostication is difficult, prognosis is inherently uncertain, and the eligibility criteria are not clearly specified

Sharon H Nahm · Martin R Stockler · Belinda E Kiely

MS risk is becoming less of a mystery as we gain a better understanding of its causes

Bruce V Taylor

A 76-year-old woman with no significant medical history presented to hospital after 3 days of vomiting

Nicholas M Stacey · Martin Feddersen

An otherwise well 45-year-old sheep farmer presented to her general practitioner following a one-week history of tender reddish-blue nodules on the dorsal surface of her left hand

Joshua Farrell · Thomas J Stewart

During times of medical crisis, reputable general medical journals are needed more than ever

Nicholas J Talley

No single surveillance system is perfect, but integrating data from multiple sources can provide comprehensive and reliable signal detection

Allen C Cheng · Jim P Buttery

Despite its potential value, a number of questions require answers before its role in clinical practice becomes clear

Mark Little

The Australian health system can respond effectively to monkeypox, especially with good surveillance, testing and tracing and rapidly procuring third generation vaccines and antivirals

C Raina MacIntyre · Andrew E Grulich

AusVaxSafety active surveillance affirms the short term safety of Comirnaty and Vaxzevria vaccines in a large population sample

Lucy Deng · Catherine Glover · Michael Dymock · Alexis Pillsbury · Julie A Marsh · Helen E Quinn · Alan Leeb · Patrick Cashman · Thomas L Snelling · Nicholas Wood · Kristine Macartney

Quantitative D-dimer assessment 2‒6 hours after snakebite could aid early diagnosis of envenoming with venom-induced consumption coagulopathy

Geoffrey K Isbister · Tina Noutsos · Shane Jenkins · Katherine Z Isoardi · Jessamine Soderstrom · Nicholas A Buckley

The optimal use of online risk tools in practice and barriers to patient access should be investigated

Australian Melanoma Centre of Research Excellence Study Group

Timely introduction of allergens did not reduce breastfeeding or increase extremely early introduction to solid foods

Jennifer Koplin · Victoria Soriano · Merryn Netting · Rachel Peters

New recommendations for the pharmacological management of heart failure

Andrew P Sindone · Carmine De Pasquale · John Amerena · Christine Burdeniuk · Alicia Chan · Andrew Coats · David L Hare · Peter Macdonald · Aaron Sverdlov · John J Atherton

To the Editor: The article by Iorfino and colleagues1 presents interesting follow‐up data on young people attending two mental health clinics. For 1510 of 2901 young people who presented in 2008–2018 with anxiety, mood or psychotic disorders, the authors identified trajectories in social and occupational functioning over 2years. Iorfino and colleagues describe the model as “primary care‐based” and “low intensity”, but it is neither generalist primary care nor low intensity as it comprises headspace plus specialised services and hospitalisation if needed. Several limitations, including 48% of patients excluded and the lack of a comparison group, make any conclusions problematic. Box 3 suggests little average change, but a latent class analysis suggests that one‐third participants who were well functioning at baseline had good functional outcomes, while the remaining two‐thirds “had generally poor functional outcome patterns”. The data are compatible with a range of conclusions, including “findings suggest that employment and engagement in education and training are protective” or “the treatment model makes no discernible difference to young people’s social and occupational functioning”. Yet Iorfino and colleagues claim that “findings suggest that the current primary care‐based model meets the needs of only a minority of young people seeking care” and call for “more comprehensive and multidisciplinary approaches because of substantial comorbidity, ambiguous or attenuated symptomatology”. This sounds like general practice, where undifferentiated illness and multimorbidity are the norm. Contrary to Iorfino et al, who state that “conclusions about the effects of specific treatments cannot be drawn”, McGorry in the accompanying editorial2 claims that findings “clearly illustrate what else is needed” — “more sustained, expert, and multidisciplinary care”. He uses the editorial to champion headspace and request yet more financial support. McGorry characterises the two‐thirds with persisting poor functioning as the “missing middle” for whom he advocates scaling up his model of care, developed for people with psychosis, to “be rapidly installed across the nation”, claiming “Countless lives and futures will be saved”. Given the uncertainty of the evidence, it is difficult to understand how such sweeping claims have survived the peer review process. Decisions on investment in mental health care should be based not on rhetoric, but on a rigorous and impartial review of the evidence and research to develop the evidence base.

Katharine A Wallis · Nicholas A Zwar · Paul P Glasziou

In reply

Frank Iorfino · Elizabeth M Scott · Ian B Hickie

In reply: In response to Wallis and colleagues,1 their interpretation of the Iorfino et al2 article is incorrect. Being fully acquainted with the youth mental health service described, I am clear that what was provided to most patients in the sample reported is in fact low intensity and primary care. Multiple publications on headspace, two independent evaluations3,4 (a third is in progress), and the huge national dataset routinely collected by headspace are also broadly consistent with the findings of this article. It is true, as Wallis and colleagues state, that in headspace, as in general practice more widely, there is a large subset of patients with multiple morbidity and more complex and persistent conditions. That is the whole point of the article. While most patients in primary care with medical complexity are generally able to access and secure tenure within the next tier of care (ie, specialist care), that is simply not the case for young people with mental ill health and mental illness. This leads to Wallis and colleagues’ critique of the solution that Iorfino et al proposed, and upon which I elaborated in my editorial.5 This solution — namely that platforms of multidisciplinary care with more secure tenure be established as a back‐up system — is pretty obvious and is a feature in all credible recent blueprints for reform. For young people aged 12–25years, this means expanding the diagnostic reach and national coverage of the six (soon to be eight) regional early psychosis platforms. Wallis et al describe my characterisation of such a proposal as “rhetoric”. In fact, the early psychosis model of care is supported by Cochrane level 1 evidence and three decades of worldwide experience and scaling up across many high income countries, including the United Kingdom, the United States, Canada, Denmark and Hong Kong. They are now the international standard of care for this group of patients. Indeed, the existing early psychosis programs funded by the federal government are producing functional outcomes as good or better than anywhere in the world, with high fidelity.6 They most assuredly save lives and futures. In any event, we can all agree that “decisions on investment in mental health care should be based not on rhetoric, but on a rigorous and impartial review of the evidence and research to develop the evidence base”. That is exactly the approach that my colleagues and I, and indeed the whole early intervention field, have always pursued, and continue to, as we expand the diagnostic coverage of these programs.

Patrick D McGorry