Volume 224 Issue 2

This editorial highlights three studies that collectively offer a roadmap towards system-level improvement in access, flow and quality of care. These studies used linked data from several Queensland hospitals and explored emergency department (ED)–hospital capacity associations with ambulance, ED and hospital dysfunction. One study found ED occupancy was strongly associated with ambulance dysfunction (ramping, response times). The second study associated hospital occupancy with ED dysfunction. Larger hospitals with occupancies above 85%–90% became dysregulated with rapid overcrowding. The modelling study in three tertiary hospitals reported that reduced admissions (ED or elective procedures), improved discharges (earlier, quicker community discharge, home care) and flexible bed use (any ward, over-census) improved flow. Diverting general practice–type attendances and weekend surgery seemed ineffective. Rapid, adequate flexible admitting capacity seems important for safe, efficient hospital–ED care and ambulance function.

David Mountain

Coronary artery disease is a major cause of death among Australians, yet current risk prediction models often misclassify patients. Coronary artery calcium (CAC) scoring provides a reproducible measure of subclinical atherosclerosis and is one of the strongest predictors of future cardiovascular events, particularly in asymptomatic adults. Although CAC scoring is widely used internationally, its uptake in Australia is constrained by the lack of public reimbursement, conditional guideline recommendations and the potential for access, especially among Aboriginal and Torres Strait Islander peoples. Incorporating CAC into national prevention strategies, subsidising scans for appropriate patients and supporting general practitioner use could improve precision and cost-effectiveness in cardiovascular disease prevention.

Shaun Khanna, Tej Dugal, Jason Kaplan, Aditya Bhat

The Intergovernmental Panel on Climate Change (IPCC) acknowledges the existing robust data that show that climate change substantially and negatively affects human health both directly and indirectly, with Indigenous people facing heightened vulnerability. The health impacts of climate change make litigation an important means of pursuing justice and strategically challenging legal systems that are not taking sufficient steps to reduce the impacts of climate change. This article invites medical professionals to learn from recent climate litigation cases and calls on professionals to listen deeply, act in allyship, and embrace legal and cultural literacy as core to delivering health equity in a changing climate.

Francis Nona, Nina Lansbury, Rowena Maguire, Britta Wigginton

Lung cancer remains Australia's leading cause of cancer death, with a disproportionately high burden on Aboriginal and Torres Strait Islander peoples. The recent launch of the National Lung Cancer Screening Program (NLCSP) offers an exciting and critical opportunity to improve outcomes. However, the program's full potential may not be met due to substantial systemic shortfalls. Key challenges include inadequate access to multidisciplinary workforce, limited access to personalised medicine and a lack of a national clinical quality registry. To maximise the NLCSP's impact, strategic investment is urgently needed to strengthen clinical infrastructure, enhance research and ensure equitable access to care.

Fraser J. Brims

IntroductionThe Australian clinical guideline for diagnosing and managing acute coronary syndromes 2025 establishes a new clinical standard for the diagnosis and management of acute coronary syndromes (ACS) in Australia. The new guideline replaces the 2016 guideline, representing the first major update in nearly a decade.Main RecommendationsThe new guideline features critical new information, including: (1) new terminology and revised definition of myocardial infarction; (2) electrocardiogram (ECG) patterns of acute coronary occlusion myocardial infarction (ACOMI), beyond ST-segment elevation; (3) use of clinical decision pathways incorporating high-sensitivity cardiac troponin (hs-cTn) assays for more efficient risk assessment; (4) stronger emphasis on the optimal timing of primary percutaneous coronary intervention in people with ST-segment elevation myocardial infarction (STEMI); (5) use of intravascular imaging-guided percutaneous coronary intervention in people with non-ST-segment elevation acute coronary syndromes (NSTEACS); (6) treatment guidance for specific groups, including those with cardiogenic shock, multivessel disease or spontaneous coronary artery dissection; (7) timing of platelet P2Y12 inhibitor administration in STEMI and NSTEACS; (8) more detailed advice on post-discharge care, including cardiac rehabilitation and secondary prevention programs, medicine adherence strategies, vaccinations and screening for mental health conditions; (9) treatment algorithms to enable more tailored prescribing of antiplatelet and anticoagulation therapies; (10) new recommended treatment target for low-density lipoprotein cholesterol (LDL-C); and (11) new recommendations on select medicines including PCSK9 inhibitors, β-blockers and angiotensin receptor-neprilysin inhibitors.Changes in Management as a Result of the GuidelineThe new guideline introduces key practice changes including broader recognition of ECG patterns of ACOMI, integration of hs-cTn testing into clinical decisions pathways and selective use of intravascular imaging in NSTEACS. Updated P2Y12 inhibitor timing, stricter LDL-C targets and PCSK9 inhibitor use support more tailored and evidence-based care in the secondary prevention of ACS. The full guideline is available at www.heartfoundation.org.au/for-professionals/acs-guideline.

David B. Brieger, Louise A. Cullen, Tom G. Briffa, Sarah Zaman, Ian A. Scott, Cynthia Papendick, Elaine Ho, Victoria Leitch, Dannii Dougherty, Garry Jennings

Melanoma represents a significant burden on the Australian healthcare system and early detection is crucial to improve patient and health system outcomes. Experts suggest that targeted screening for high-risk individuals could lead to more efficient use of healthcare resources. Integrated risk scores combine polygenic risk scores (PRS) and non-genetic risk factors to offer the best performance for melanoma risk stratification. However, the feasibility of using integrated risk scores on a population basis to identify those at highest risk has yet to be evaluated. This narrative review aimed to identify evidence gaps and key issues to be addressed to support implementation of melanoma integrated risk scores on a population-based scale in Australia. Findings highlighted the following research and infrastructure needs: understand the progression rate of melanoma in situ to invasive disease; define who should be offered integrated risk scores; address performance issues across ancestries; develop clearly defined risk thresholds and corresponding clinical advice; and investigate clinical utility and impact of receiving integrated risk scores. Furthermore, screening programmes will require: equitable access to post-screening care; guidelines and quality standards for generating PRS and integrated risk scores; healthcare rebates for PRS testing; infrastructure for computational and data storage needs; workforce training and clinical decision support resources; clearer protections around PRS use in risk-rated insurances; and clear plans for programme quality and performance management. In conclusion, integrated risk scores have potential to facilitate targeted high-risk melanoma screening in Australia. However, there are significant evidence and infrastructure gaps that must be addressed before programme implementation.

Courtney K. Wallingford, Chloe Mighton, Tamara Dawson, Anne Cust, H. Peter Soyer, Yvonne Bombard, Tatiane Yanes, Aideen McInerney-Leo

ObjectiveTo explore the characteristics of ambulance ramping and its association with access block before, during and after the first wave of the coronavirus disease 2019 (COVID-19) pandemic.DesignRetrospective observational study.SettingExploratory data analysis and statistical modelling covering the ambulance–emergency department (ED) interface of the 25 largest public hospitals in Queensland between 1 January 2018 and 31 December 2022.Main Outcome MeasuresPrimary outcome: The association between ramping, assessed as the ambulance performance target patient off-stretcher time (POST) and access block, and how COVID-19 affected these time-sensitive processes. Secondary outcomes: The association between POST and ambulance response time and between ramping and ED length of stay.ResultsA significant decline in POST performance was observed across the study period, with the mean difference between pre– and post–COVID-19 periods being 13.1min (95% CI, 12.9–13.3min) and 8.9min (95% CI, 8.7–9.1min) for Priority 1 and Priority 2 responses, respectively. POST compliance within 30min dropped from 74% (718,912) pre–COVID-19 to 66% (694,633) during the first wave of COVID-19 and 57% (309,815) post–COVID-19, all below the 90% target. The proportion of patients experiencing access block increased from 10% (91,168) to 17% (87,757) over this same time period. Regression analyses revealed a positive relationship between POST and access block, response time and POST, and ramping and ED length of stay. Before COVID-19, no significant relationship existed between POST and access block for triage category 1 patients, but longer POST was linked to a higher likelihood of access block for categories 2–5. This trend increased across all categories during and post–COVID-19.ConclusionAchieving the POST target of transferring 90% of patients within 30min is becoming more difficult, with performance declining. The strong association of POST with access block suggests that access block is driving ramping increases. To reduce delays, efforts should focus on improving access to ward beds and managing hospital capacity issues.

Hwan-Jin Yoon, Justin Boyle, Ibrahima Diouf, Emma Bosley, Andrew Staib, Vahid Riahi, Hamed Hassanzadeh, Mahnaz Samadbeik, Clair Sullivan, Sankalp Khanna, James F. Lind

Objectives To evaluate the effect of hospital occupancy levels on inpatient and emergency department (ED) flow rates, ED length of stay (ED) and access block, and identify critical occupancy thresholds above which patient flow deteriorates. Design Retrospective cohort study using routinely collected administrative data. Setting Twenty-five public hospitals in Queensland, Australia, over a 5.5-year period (1 April 2017 to 31 August 2022). Main Outcome Measures ED presentation and discharge rates, inpatient admission and discharge rates, hospital occupancy levels, length of stay, access block and 4-h rule compliance. Results The analysis reveals a significant performance shift as hospital occupancy levels increase and identifies site-specific critical ‘choke points’ where patient flow deteriorates. Notably, as occupancy rises, we observed a growing divergence between ED presentations and discharge rates, and between inpatient admissions and discharges, indicating system congestion. Additionally, when assessing flow across the 25 hospitals, the data demonstrates that a 10% increase in bed occupancy rate correlates with a 0.32-h (19-min) extension in ED length of stay (or 33min for patients admitted from the ED). Also, significant disparities in hospital operations were observed between weekends and weekdays, with weekday admissions and discharges up to three times higher than weekends, highlighting the increased operational pressure during the work week. Conclusions The investigation challenges the traditional 85% occupancy target, demonstrating that optimal occupancy levels vary by hospital. The study also underscores the strong correlation between hospital bed occupancy and ED access performance, with higher hospital occupancy correlating with longer ED stays and decreased adherence to performance indicators. As hospitals approach full capacity, the pressure on ED resources intensifies, resulting in longer wait times and delays in care.

Vahid Riahi, Justin Boyle, Hwan-Jin Yoon, Hamed Hassanzadeh, Ibrahima Diouf, Sankalp Khanna, Andrew Staib, Mahnaz Samadbeik, Clair Sullivan, Emma Bosley, James F. Lind

Objective To assess the impact of strategies to improve public hospital emergency access using a detailed ward-level simulation modelling approach. Design and Setting Discrete event simulation was used to simulate patient flow at three principal referral Australian hospitals from 1 September 2021 to 31 August 2022. Models were developed and validated using every emergency department (ED) presentation, inpatient episode of care and patient ward movement at the study hospitals. Main Outcome Measures Mean and total ED length of stay, mean waiting time, access block rate, 4-h rule compliance and bed utilisation for patients admitted from the ED. Results Reducing ED demand via arrangements that accommodate the same proportion and types of admissions from the ED as the existing ED presenting population reduces access block, with larger impacts in winter than in summer. However, reducing ‘general practitioner-type patients’ in EDs has negligible impact on access block. Tangible impacts on improving patient flow can be achieved by removing maintenance care patients from hospitals (reducing the percentage of access block by up to a third) and reducing elective admissions. Strategies that emphasised morning, midday and early afternoon discharges led to large flow improvements. The strategy already practised by most hospitals of sharing patients among wards greatly improves emergency access, and gains are the same order of magnitude as reducing overall ED demand. Conclusions The study provides support to policymakers looking for evidence regarding strategies to improve emergency access to public hospital care.

Hamed Hassanzadeh, Justin Boyle, Vahid Riahi, Hwan-Jin Yoon, Ibrahima Diouf, Sankalp Khanna, Clair Sullivan, Andrew Staib, Emma Bosley, Mahnaz Samadbeik, James F. Lind

Objectives To examine spatial, temporal and seasonal patterns in childhood and adolescent asthma hospitalisations across Queensland, and assess variation in hospitalisation risk by age and sex across climate regions. Design A retrospective, population-based ecological study using area-level administrative data from hospital admissions. Setting All public and private hospitals in Queensland, Australia, 1 January 2000–31 December 2019. Participants Children and adolescents aged 0–19years who were admitted to hospital with a principal diagnosis of asthma. Main Outcome Measures Age-standardised admission rates and relative risks (RRs) from spatial models; temporal patterns from time-series analysis; spatial variation from mapping; age-, sex- and climate zone-specific risks. Results Hospitalisations among children aged 0–4years declined from 48.1% (1640 admissions) in 2000 to 23.2% (721 admissions) in 2019, whereas proportions in older age groups increased. Seasonal peaks occurred in May, June and February, with male patients showing a stronger February peak and female patients maintaining higher risks into July. Hot desert regions had the highest RRs, rising from 3.73 (95% credible interval [CrI], 3.71–3.74) in 2000–2001 to 9.37 (95% CrI, 9.28–9.47) in 2009–2010, then declining to 2.37 (95% CrI, 2.37–2.38) in 2018–2019. Hot semi-arid and tropical savanna regions showed persistently elevated risks (hot semi-arid: RR, 1.86–3.75; tropical savanna: RR, 1.81–4.58). Three temporal phases were evident statewide: an early lower-risk period (2000–2002), a higher-risk period (2002–2012) and a later reduction (2012–2019), with most RRs between 0.5 and 1.5. Seasonality was strongest in hot desert zones (seasonal strength, 0.519) and weakest in tropical savanna zones (0.063). Conclusions Childhood and adolescent asthma hospitalisations in Queensland exhibit significant spatiotemporal variation, with burden shifting from younger to older children, and climate-specific risks, although observed reductions in the youngest age group may partly reflect diagnostic and hospital admission practice changes. Higher asthma risks in arid and tropical savanna regions underscore the need for geographically tailored services and planning. These findings suggest that targeted public health strategies might help reduce asthma burden in vulnerable communities.

Jialu Wang, Javier Cortes-Ramirez, Janet Davies, Wenbiao Hu

ObjectiveTo examine the features of interval colorectal cancer (interval CRC) in Western Australia in the context of the National Bowel Cancer Screening Program (NBCSP), including incidence, characteristics and survival by NBCSP participant characteristics.Study DesignRetrospective observational cohort study, analysis of linked National Cancer Screening Register and Western Australian Cancer Registry data.Participants, SettingParticipants in the Western Australian NBCSP (50–74years of age) with negative immunochemical faecal occult blood test (iFOBT) results during the 2018 screening round (1 January 2018–31 December 2018) were followed up for interval CRC diagnoses until 31 December 2020, and for death until 30 September 2022.Main Outcome MeasuresCrude and adjusted incidence rates of interval CRC were analysed overall and by sex, age group and residential socio-economic and remoteness categories. Survival outcomes for people with interval CRC were also assessed.ResultsOf 122,851 NBCSP participants with negative screening results in 2018, 51 people were diagnosed with interval CRC during follow-up (crude incidence rate, 21 per 100,000 person-years; 95% confidence interval [CI], 16–27). The adjusted incidence rate ratio of interval CRC was higher for men than women (adjusted incidence rate ratio [aIRR], 5; 95% CI, 3–11) and for people aged 70–74years than for those aged 50–59years (aIRR, 3; 95% CI, 1–6). Nineteen of 51 interval CRCs were diagnosed 19–24months after negative iFOBT results, 25 were located on the right side of the colon and 34 were adenocarcinomas. Only 13 interval CRCs were stage I tumours at diagnosis. During follow-up (median, 33months; interquartile range, 28–42months), the all-cause mortality rate among the 51 people with interval CRC was 41 per 1000 person-years (95% CI, 18–92), and the colorectal cancer mortality rate was 35 per 1000 person-years (95% CI, 14–83).ConclusionsWe provide a comprehensive analysis of interval CRC staging and clinical characteristics in the context of the NBCSP in Western Australia, facilitating the definition of benchmarks for monitoring programme performance.

Shantelle J. Smith, Rachael Moorin, Dagmawi Tadesse, Kathleen O'Connor, Thi Ninh Ha

ObjectivesTo examine the extent and nature of lived experience engagement in Australian clinical practice guideline development.Study DesignScoping review of Australian clinical practice guidelines published 1 January 2014–20 March 2025 that reported using a systematic search method and standardised methods for appraising evidence quality and certainty.Data SourcesPubMed, Guidelines International Network library, Google Scholar, the websites of all 25 Australian medical colleges, the Cancer Council, the Heart Foundation, the Stroke Foundation, the National Blood Authority and Caring for Australians and New Zealanders with Kidney Impairment.Data SynthesisOne hundred and fifty guidelines met the inclusion criteria; 108 (72%) reported some degree of lived experience engagement in their development, of which 98 (91%) described engagement through all development stages and 95 (88%) reported their inclusion as guideline panel members. Other methods of engagement included participation in lived experience panels and advisory groups (10 guidelines, 9%) and online surveys (5 guidelines, 5%). Ninety-seven of 108 guidelines (90%) with lived experience engagement reported that people with lived experience were asked to decide, advise or vote on recommendations or guideline content. One person with lived experience participated in the development process for 61 guidelines (56%), two people for 14 guidelines (13%), 3–10 people for 19 guidelines (18%) and more than 10 people for 10 guidelines (9%). Little information was reported about the characteristics of participating people with lived experience. Sixty guidelines (56%) reported remunerating people with lived experience for their participation, 49 guidelines (45%) reported that they received practical support and 41 guidelines (38%) reported that group dynamics were managed to support lived experience engagement.ConclusionsIt is encouraging that most Australian guidelines published during 2014–2025 reported at least some lived experience engagement in their development. However, extensive lived experience engagement was not reported for the vast majority of guidelines. The engagement of people with lived experience in guideline development needs to be improved to ensure that their values, views and preferences are reflected.

Naomi MacPherson, Thomas Benning, Bernard Tso, Chuyue Wang, Antonia Arfaras, Brian A. Beh, Vanessa Cullen, Jessica D'Lima, Tony Finneran, David C. Fry, Michelle King, Alexander Meredith, Adrian O'Malley, Joanne Muller, Tari Turner, Samantha P. Chakraborty

Rigel Paciente, Keely Bebbington, Alix Woolard, Helen Milroy