Issues
Volume 218 Issue 2
Editor’s choice
Highlighting equity and inequity in Australia’s health system
Equity and inequity in Australia's health system are major themes in this latest issue of the MJA. From the beginning, when research is funded, through to how clinical guidelines are developed, how research is conducted, and, finally, in health outcomes, the articles in this issue explore gender and racial inequities from several angles, including what progress has been made, and where deficiencies remain. Together they highlight how diversity and inclusivity in generating and applying medical evidence is fundamental to ensuring our health system achieves equitable and high quality outcomes for all patients. In her Perspective Towards gender equity in Australian health and medical research funding, the NHMRC CEO, Professor Anne Kelso, describes an important new initiative by the leading Australian health research funder to reduce gender disparities in one key area: the Leadership levels of the Investigator Grant scheme. This measure, informed by evidence and consultation across the Australian health research sector, is welcome, and is hopefully a start towards reducing the attrition of women at early and mid‐career stages. I was especially heartened to see that its “goals are defined, its effectiveness will be monitored annually, and it will cease if it is found to be ineffective or to have achieved its goals” (doi: 10.5694/mja2.51767). Continuing the theme of gender inequity, Anna Shalit and colleagues found that women were underrepresented in Australian clinical guideline development groups over the 10‐year period, 2010–2020, especially when it comes to women in leadership as panel chairs. The authors recommend that organisations which “develop or endorse guidelines should adopt effective policies for gender balance on their guideline panels and regularly monitor progress toward this target” (doi: 10.5694/mja2.51831). For their Research article on Ethical conduct in research with Aboriginal and Torres Strait Islander peoples and communities, Luke Burchill and colleagues surveyed people working in Indigenous health research in Australia about their use of the 2018 NHMRC guidelines, and the degree of Indigenous governance and participation in their research. Their findings are essential reading for anyone working in Indigenous health. Although the NHMRC guidelines are widely used, along with local guidelines, the authors conclude that “Indigenous governance and participation was inadequate at each stage of research” and that “Indigenous health research in Australia is largely informed by non‐Indigenous world views, led by non‐Indigenous people, and undertaken in non‐Indigenous organisations” (doi: 10.5694/mja2.51757). In their linked editorial, Aboriginal and Torres Strait Islander health research leadership, Candice McKenzie and Lilon Bandler emphasise how sobering these findings are, noting that “As only 38% of [the survey] respondents had received any formal education in the history of health research involving Indigenous people, more than 60% may not have properly understood the historical background underpinning the need for and value of the [NHMRC] guidelines.” They call for more than just a commitment to strengthening capacity building among Aboriginal and Torres Strait Islander health researchers: “We support the development of a required course on the ‘legacy of health research exploiting Indigenous Peoples’ that examines the eight domains of the Consolidated criteria for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement” (doi: 10.5694/mja2.51827). The complex interplay of societal and health system factors that lead to inequitable health outcomes is examined by Paul Secombe and colleagues in their analysis of 12‐month mortality for Indigenous and non‐Indigenous people admitted to intensive care units in Australia. They find that “survival outcomes are poorer for Indigenous than non‐Indigenous people admitted to ICUs”, but conclude that it “is likely that the difference is less directly attributable to the ICU admission than to a complex interplay between pre‐ and post‐hospitalisation factors, socio‐economic disadvantage, remoteness, and chronic disease trajectory”. This is a message that should resonate well beyond this article across the entire Australian health system (doi: 10.5694/mja2.51763). 2023 is likely to be another challenging year for the Australian — and the global — health systems. The MJA team is committed to addressing these challenges in the research and commentary we publish, and look forward to working with authors, reviewers, and other colleagues from across the health community in the year ahead.
Virginia Barbour
Perspectives
Show me the money: how do we justify spending health care dollars on digital health?
Focusing solely on financial measures is unlikely to deliver a comprehensive view of the value of digital health
Leanna Woods · Rebekah Eden · Oliver J Canfell · Kim‐Huong Nguyen · Tracy Comans · Clair Sullivan
Towards gender equity in Australian health and medical research funding
From 2023, the National Health and Medical Research Council aims to award equal numbers of Investigator Grants to women and men
Anne Kelso
Controversies in the management of proximal deep vein thrombosis
Future studies should focus on patient selection for interventional therapy, best practices for stent surveillance, and long term anticoagulation
Jana‐Lee Moss · Frederikus A Klok · Uyen G Vo · Toby Richards
The Mobile Outreach Boomerang van: taking care to the community
Indigenous-specific mobile clinics improve access to health care by delivering care to underserviced communities
Deborah A Askew · Ethan Kettyle · Kim Passante · Tamika Campbell · Maree R Toombs
Medical education
Keratinocyte cancer in chronic smokers: is this arsenic exposure?
An 83-year-old woman of European ancestry had an initial diagnostic consideration of arsenical keratosis
Lachlan DW Lau · Anneliese Willems · Laura Scardamaglia
Editorials
Centering the Medical Journal of Australia in the landscape of medical information in 2023
The MJA has a unique responsibility and opportunity to report, reflect, and advocate health priorities across Australia and our region
Virginia Barbour
Beyond the intensive care unit: ensuring the long term health of critically ill Indigenous people
An important aim after critically ill Indigenous people return home is to avoid the need for re-admission to hospital
Dianne P Stephens
Gender diversity of clinical practice guideline panels in Australia: important opportunities for progress
Gender balance can lead to more focused recommendations and better health outcomes for everyone
Cheryl Carcel · Mark Woodward
Aboriginal and Torres Strait Islander health research leadership
When will we see Indigenous Australians move from being the examined to being the examiners?
Candice McKenzie · Lilon G Bandler
Research
Twelve‐month mortality outcomes for Indigenous and non‐Indigenous people admitted to intensive care units in Australia: a registry‐based data linkage study
After adjusting for age and other factors, survival outcomes are poorer for Indigenous than non-Indigenous people admitted to ICUs
Paul J Secombe · Alex Brown · Michael J Bailey · Sue Huckson · Shaila Chavan · Edward Litton · David Pilcher
The representation of women on Australian clinical practice guideline panels, 2010–2020
The gender balance of guideline panels should be improved to ensure high quality and equitable health care for all
Anna Shalit · Lauren Vallely · Renae Nguyen · Meghan Bohren · Agnes Wilson · Caroline SE Homer · Joshua Vogel
Ethics guidelines use and Indigenous governance and participation in Aboriginal and Torres Strait Islander health research: a national survey
Barriers that limit the oversight of and participation of Indigenous people in Indigenous health research should be overcome
Luke J Burchill · Aneta Kotevski · Daniel LM Duke · Jeanette E Ward · Megan Prictor · Karen E Lamb · Michelle Kennedy
Research letter
Non‐fatal opioid overdose after release from prison among men who injected drugs prior to their imprisonment: a prospective data linkage study
Re-introducing public opioid agonist therapy clinics in Victoria could improve accessibility for some people recently released from prison
Michael Curtis · Paul Dietze · Rebecca J Winter · Kasun Rathnayake · Karen Smith · Mark Stoove
Letters
Differences in the pre‐hospital management of women and men with stroke by emergency medical services in New South Wales
To the Editor: We read the article by Wang and colleagues1 with great interest. In their study, they used linked administrative datasets from 2005 to 2018 to investigate sex differences in pre‐hospital management of patients with stroke from a single jurisdiction. Among their findings, they observed that a greater proportion of women (52.4%) than men (47.9%) arrived at hospital by ambulance. We seek to draw attention to a similar, nationally representative study on the factors associated with the use of ambulances and access to evidence‐based care among patients with stroke.2 Our study included patients with first‐ever strokes from the Australian Stroke Clinical Registry (2010–2013) linked with administrative data (emergency, hospital admissions),2 as part of the Stroke123 study3 (including 39 hospitals from New South Wales, Queensland, Victoria and Western Australia). We found that among the 6262 patients with first‐ever stroke, 4737 (76%) arrived by ambulance.2 Interestingly, we also found sex differences in arrival by ambulance before adjustment for other covariates (women, 78.8% v men, 72.9%).2 In the Stroke123 study, we adjusted for factors associated with ambulance arrival.2,3 Some of the factors most strongly associated with ambulance arrival were age, frailty and markers of stroke severity. We found that patients who were older, frailer and had more severe strokes were more likely to arrive by ambulance. Following adjustments for age and stroke severity, the sex differences were no longer statistically significant.2 In other research undertaken by our group using linked ambulance, hospital and Australian Stroke Clinical Registry data, other important factors associated with arrival by ambulance included call‐taker or paramedic identification of stroke, which was less often identified in women.4 In the investigations on sex differences by Wang and colleagues, there was no adjustment for markers of stroke severity. We are curious as to why no adjustment for Glasgow Coma Scale was made, particularly when looking at assessment for stroke by paramedics. It is possible that the sex differences observed would not be as marked after adjusting for stroke severity.
Monique Kilkenny · Amminadab L Eliakundu · Joosup Kim
Differences in the pre‐hospital management of women and men with stroke by emergency medical services in New South Wales
In reply
Xia Wang · Cheryl Carcel · Mark Woodward
Responding to both established and emerging health challenges
Virginia Barbour
Now is the time to act on nutrition in medical education
Eleanor J Beck · Lauren Ball · Breanna M Lepre · Rachael McLean · Clare Wall · Melissa Adamski · Helen McCarthy · Jennifer Crowley
Cardiovascular disease risk screening in Australia: evidence and data gaps
Ellie Paige · Natalie Raffoul · Emma Lonsdale · Emily Banks
Designing digital health applications for climate change mitigation and adaptation
Zerina Lokmic‐Tomkins · Ann Borda · Kimberly Humphrey
Supporting Indigenous health equity strategic planning: a Queensland perspective
Maree R Toombs · Caitlin Curtis · Claire E Brolan
Access to voluntary assisted dying in Australia requires fair remuneration for medical practitioners
Casey M Haining · Lindy Willmott · Simon Towler · Ben P White
DANGER: what clinicians need to know about aggressive head and neck cutaneous squamous cell carcinoma
Richard Tjahjono · Hubert TH Low · Jenny Lee · Deshan F Sebaratnam · Ruta Gupta · Michael J Veness · Jonathan Clark · Carsten E Palme
An important case of atypical pneumonia
Arvind Yerramilli · Michelle Sam · Aadith Ashok · Eugene Athan