Consensus statements

IntroductionDespite evidence of improved outcomes, people with pancreatic cancer have highly variable access to effective pain relief and palliative care. We aimed to develop evidence-based, community-informed standardised pathways to timely pain management and early palliative care for people with pancreatic cancer.Main RecommendationsUsing a multi-method, comprehensive, community engagement and evidence-informed approach, we developed pathways to standardise referral to pain management and early palliative care for people with pancreatic cancer. Community engagement included representation from multidisciplinary clinicians, community groups and people with lived experience from across regions and all Australian states. We developed two pathways: (i) a pathway for pain management for people with resectable pancreatic cancer and (ii) an integrated pathway for pain management and palliative care for people with unresectable pancreatic cancer (https://www.pancare.org.au/pancreatic-cancer-roadmap-projects/pancreatic-cancer-pathways). Clinical guidance providing practical steps and links to evidence accompany the pathways. Key elements of the pathways included:screening for pain at each encounter, comprehensive holistic assessment and management;early consideration of interventional pain management in the event of refractory pain;introduction of palliative care at time of diagnosis of metastatic or unresectable pancreatic cancer with links to suggested language to address potential community hesitancy; andrecommendation to discuss referrals for palliative care and interventional pain management at cancer multidisciplinary meetings.Changes in Management as a Result of the GuidelinesThe pathways developed have set forth best practice standards grounded in evidence and expert consensus. The extensive clinical and community engagement ensures the relevance and ownership of these pathways. Implementation of the pathways will reduce existing variation in access and enhance the quality of care for people with pancreatic cancer. Furthermore, the pathways offer an opportunity to benchmark practice within and between services.

Jennifer Philip, Melanie R. Lovell, Kylee Bellingham, Gail Garvey, Gregory B. Crawford, Nicole M. Rankin, Kara Burns, Isabel Young, Vivienne Milch, Dorothy Keefe, Katrina Anderson, James Lawson, Meinir Krishnasamy

Introduction For many people entering custody, abrupt changes in alcohol or other drug use is associated with the risk of experiencing a withdrawal syndrome. Management of withdrawal from alcohol and other drugs in a custodial setting is complicated by both a limited evidence base and structural barriers to the delivery of best practice healthcare interventions to people in custody. Main Recommendations A multidisciplinary expert panel representing all Australian states and territories participated in a modified Delphi process. The process generated 22 recommendations to custodial services, health services and government for the management of withdrawal from alcohol and other drugs in custodial settings across five domains: screening for withdrawal risk; assessment of withdrawal; management of withdrawal; specific considerations for the care of First Nations people; and organisational support. Notable recommendations include using universal and timely assessment for withdrawal at reception to custody; using validated clinical tools and evidence-based interventions to assess and manage withdrawal syndromes; and ensuring that the safest location for withdrawal from alcohol or other drugs is provided. Changes in Management as a Result of the Statement This statement presents best practice standards for the management of withdrawal from alcohol and other drugs in Australian custodial settings, as informed by evidence and expert consensus. Implementing the recommendations set out in this statement will improve the quality and consistency of withdrawal care provided to people entering Australian custodial settings and reduce harms associated with incarceration for people who use alcohol and other drugs. This statement has been endorsed by the Royal Australasian College of Physicians, the Australasian Professional Society on Alcohol and Other Drugs, the National Prisons Hepatitis Network, the Pharmaceutical Society of Australia and the Australian Injecting and Illicit Drug Users League. The statement is also approved as an Accepted Clinical Resource by the Royal Australian College of General Practitioners.

Grace FitzGerald, Jocelyn Chan, Jon Cook, Mark Stoove, Michael Curtis, Suzanne Nielsen, Rebecca J. Winter, Thileepan Naren

Introduction Patent foramen ovale (PFO) is implicated in 25%–50% of cryptogenic strokes in patients aged <60years. Recent clinical trials demonstrated the benefit of PFO closure in selected patients. However, there is considerable variability in Australian and New Zealand clinical practice regarding investigation and management approaches. A multidisciplinary consensus group comprising stroke neurologists and an interventional cardiologist from major centres employed a modified nominal group technique to develop evidence-based recommendations for standardising PFO-associated stroke management. Main Recommendations Twelve recommendations were developed across three domains. For patient selection: Universal PFO screening for cryptogenic stroke patients aged ≤60years, with selective screening for patients aged >60years with embolic stroke of undetermined source, absent vascular risk factors and excluded atrial fibrillation. For diagnostic investigations: Transcranial Doppler (TCD) bubble study as preferred first-line screening where available, with transthoracic echocardiography as an alternative when TCD is unavailable and transoesophageal echocardiography for confirmation before closure consideration. For treatment decisions: Incorporation of the PFO-Associated Stroke Causal Likelihood (PASCAL) classification system rather than the Risk of Paradoxical Embolism (RoPE) score alone, consideration of TCD grading results for risk stratification and mandatory multidisciplinary heart–brain team evaluation for all closure decisions. Changes in Management as a Result of This Consensus Statement These recommendations will standardise practice through enhanced TCD service provision, structured heart–brain team development and evidence-based patient selection using the PASCAL classification. The emphasis on TCD as first-line screening represents a departure from traditional transthoracic echocardiography-based approaches. Implementation will improve patient outcomes through appropriate intervention in suitable candidates while avoiding unnecessary procedures in those unlikely to benefit, thereby promoting equitable access to optimal PFO management across Australia and New Zealand.

Brian R. Chambers, Lauren M. Sanders, Amanda Gilligan, Carlos Garcia-Esperon, Jan Ho, John Fink, Matias Yudi, Matthew Lee-Archer, Vimal Stanislaus, Andrew A. Wong

Introduction This consensus statement from multidisciplinary experts and consumers across Australia provides comprehensive recommendations on the prevention and management of frailty in community-dwelling older adults. Methods The study uses a modified Delphi design. Phase I involved iterative discussion among six frailty care working groups, based on current evidence and expert opinion, to draft the statements. Phase II involved validation of each statement across two Delphi rounds conducted to determine level of agreement. Main Recommendations A lifelong approach to health promotion for frailty prevention should focus on raising awareness, annual screening (65+ years) and personalised counselling around accessible health behaviours to manage chronic comorbidities. An individualised, balanced, protein-rich diet is likely to be effective in delaying the onset of frailty. Protein–energy malnutrition and nutritional deficiencies should be identified and treated. A nutrition care plan that considers the relaxation of dietary restrictions aligned with goals of care should be planned for older adults with severe frailty. Progressive, individualised and ongoing exercise should be a combination of aerobic and resistance exercise, and balance and functional training tailored to frailty level and supervised by professionals. Social prescribing for older adults should be co-designed with a link worker to support meaningful, accessible and culturally appropriate activities that foster social engagement, with plans customised to the individual's frailty level. A comprehensive, multidisciplinary medication review tailored to the older adult's health status, preferences and frailty degree helps optimise medication use, minimise harm and support functional independence across all stages of frailty. Older adults with severe frailty need a regularly reviewed, personalised care plan, which involves carers in decision-making, supports advance care planning and ensures high-quality end-of-life care. Changes in Management Informed by This Statement The consensus statements introduce an integrated, evidence-informed and consumer-focused framework to guide healthcare professionals in delivering personalised and effective care for community-dwelling older adults living with or at risk of frailty.

Lisa Kouladjian O’Donnell, Marc Sim, Michelle Miller, Peta Dampney, Pazit Levinger, Shannon King, Ruth E. Hubbard, on behalf of the Australian Frailty Network Working Group

In recognition of the increasing burden of metabolic dysfunction-associated fatty liver disease (MAFLD) in Australia, and the lack of clear guidelines for general practitioners, this consensus statement summary presents 21 recommendations on the assessment and monitoring of MAFLD in adult patients in primary care

Leon A Adams · William W Kemp · Kate R Muller · Elizabeth E Powell · Stuart K Roberts · Luis Calzadilla Bertot · Stephanie Best · Gary Deed · Jon D Emery · Samantha L Hocking · Graham R Jones · John S Lubel · Sinead Sheils · Stephen M Twigg · Gerald F Watts · Jacob George

A molecular diagnosis of monogenic diabetes can guide family planning, cascade testing and surveillance for other manifestations

Sunita MC De Sousa · Timothy ME Davis · James Harraway · Mark Greenslade · Kathy HC Wu · Ryan G Paul · Juliet Taylor · Aleena S Ali · Elif I Ekinci · Rinki Murphy · Jerry R Greenfield

Introduction: Opioid use and dependence are prevalent among incarcerated people, contributing to elevated rates of overdose and other harms in this population. Opioid agonist treatment (OAT) has been shown to be an effective intervention to mitigate these risks. However, challenges to health care implementation in the custodial sector result in suboptimal and variable access to OAT in prisons nationally. Main recommendations: Among a national multidisciplinary expert panel, we conducted a modified Delphi study that yielded 19 recommendations to government, relevant health authorities and custodial health services. These recommendations cover five core domains: induction or continuation of OAT, OAT options and administration, transition of care to the community, special populations, and organisational support. Key recommendations include prompt recognition and treatment of opioid withdrawal, active linkage to community‐based OAT providers upon release, and ensuring appropriate organisational support through local protocols, adequate funding, and monitoring of key program indicators. Changes in management as a result of this statement: This consensus statement addresses a significant gap in national policy on OAT in Australian prisons. The recommendations, finalised in July 2024, set forth best practice standards grounded in evidence and expert consensus. We expect that implementing these recommendations will enhance the quality, consistency and continuity of OAT both within prison and upon release. Optimising OAT provision is crucial for improving health outcomes and addressing the risk of overdose, which is the leading cause of death among people released from prison.

Jocelyn Chan · Jon Cook · Michael Curtis · Adrian J Dunlop · Ele Morrison · Suzanne Nielsen · Rebecca J Winter · Thileepan Naren

The emergence of Buruli ulcer in previously non-endemic areas highlights the importance of increasing clinician and community awareness of this disease

Stephen Muhi · Victoria RV Cox · Matthew O'Brien · Jonathan T Priestley · Jodie Hill · Adrian Murrie · Anthony McDonald · Peter Callan · Grant A Jenkin · N Deborah Friedman · Kasha P Singh · Callum Maggs · Peter Kelley · Eugene Athan · Paul DR Johnson · Daniel P O'Brien

This two-part position statement provides a practical resource for clinicians on current best-practice consensus recommendations for managing adults with MS in the Australian and New Zealand health care settings

the MS Interest Group, Australian and New Zealand Association of Neurologists

A safe, effective and comprehensive approach to managing MS is crucial for improving long term outcomes and quality of life in individuals affected by MS

the MS Interest Group, Australian and New Zealand Association of Neurologists

This consensus statement on doxy-PEP provides clinicians with appropriate and accurate information on doxy-PEP

Vincent J Cornelisse · Benjamin Riley · Nicholas A Medland

New recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children

Samantha Harkus · Vivienne Marnane · Isabel O'Keeffe · Carmen Kung · Meagan Ward · Neil Orr · John Skinner · Kelvin Kong · Lose Fonua · Michelle Kennedy · Mary Belfrage

Incidentally found white matter hyperintensities on neuroimaging are an opportunity to address cardiovascular risk factors to prevent progression to cognitive decline

Thomas P Ottavi · Elizabeth Pepper · Grant Bateman · Mark Fiorentino · Amy Brodtmann

Prison settings are risk environments for HCV transmission and should therefore be a priority setting for harm reduction and clinical and educational interventions

Rebecca J Winter · Yumi Sheehan · Timothy Papaluca · Graeme A Macdonald · Joy Rowland · Anton Colman · Mark Stoove · Andrew R Lloyd · Alexander J Thompson

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

Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents

Jencia Wong · Glynis P Ross · Sophia Zoungas · Maria E Craig · Elizabeth A Davis · Kim C Donaghue · Louise J Maple‐Brown · Margaret J McGill · Jonathan E Shaw · Jane Speight · Natalie Wischer · Stephen Stranks

Recommendations are based on evidence-based knowledge of safety, immunogenicity and efficacy of the vaccines in the general population, plus emerging data regarding COVID-19 vaccination in immunocompromised individuals

Eliska Furlong · Rishi S Kotecha · Rachel Conyers · Tracey A O'Brien · Jordan R Hansford · Leanne Super · Peter Downie · David D Eisenstat · Gabrielle Haeusler · Brendan McMullan · Marianne B Phillips · Bhavna Padhye · Luciano Dalla‐Pozza · Frank Alvaro · Christopher J Fraser · Wayne Nicholls · Julia E Clark · Matthew O'Connor · Benjamin R Saxon · Heather Tapp · John Heath · Sarah E Hunter · Karen Tsui · Mark Winstanley · Amanda Lyver · Emma J Best · Ushma Wadia · Daniel Yeoh · Christopher C Blyth · Nicholas G Gottardo

This statement provides guidance to managing hepatitis B, recognising groups at increased risk of HBV infection and appropriate, timely screening strategies

John S Lubel · Simone I Strasser · Alexander J Thompson · Benjamin C Cowie · Jennifer MacLachlan · Nicole L Allard · Jacinta Holmes · William W Kemp · Avik Majumdar · David Iser · Jess Howell · Gail V Matthews

Widespread adoption of high value cancer care practices during the pandemic will benefit cancer care delivery into the future

Vivienne Milch · Rhona Wang · Carolyn Der Vartanian · Melissa Austen · Debra Hector · Cleola Anderiesz · Dorothy Keefe

The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura underlines the need for contemporary guidelines relevant to the local treatment context

Philip YI Choi · Eileen Merriman · Ashwini Bennett · Anoop K Enjeti · Chee Wee Tan · Isaac Goncalves · Danny Hsu · Robert Bird

Introduction: Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care. Main recommendations: This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial‐based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies. Changes in management as result of this statement: This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with “do‐it‐yourself” technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Anthony J Pease · Sofianos Andrikopoulos · Mary B Abraham · Maria E Craig · Brett Fenton · Jane Overland · Sarah Price · David Simmons · Glynis P Ross

Introduction: The Australian Council on Healthcare Standards (ACHS) sponsored an expert‐led, consensus‐driven, four‐stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. Methods and recommendations: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. Changes in management as a result of this statement: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Eva Segelov · Christine Carrington · Sanchia Aranda · David Currow · John R Zalcberg · Alexander G Heriot · Linda Mileshkin · John Coutsouvelis · Jeremy L Millar · Brian T Collopy · Jon D Emery · Phoebe Zhang · Simon Cooper · Carmel O’Kane · Janet Wale · Stephen J Hancock · Anthony Sulkowski · John Bashford

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at‐risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators. Methods and recommendations: This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management. Changes in management as a result of this statement: This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.

John S Lubel · Stuart K Roberts · Simone I Strasser · Alexander J Thompson · Jennifer Philip · Mark Goodwin · Stephen Clarke · Darrell HG Crawford · Miriam T Levy · Nick Shackel