Article Types
Letters
Ambulance ramping, system pressure, and hospitals in crisis: what do the data tell us?
To the Editor: Recent media reports imply there is an increased pressure on Adelaide’s metropolitan emergency medical system which has resulted in additional ambulance ramping and consequent industrial action.1,2,3 We collected a novel dataset of emergency department (ED) capacity state observations at 30‐minute intervals from the public South Australia ED Dashboard4 to investigate the claims of increased pressure. The dashboard uses a traffic light system to indicate ED busyness. The 7‐day moving average of the daily percentage of EDs in “green” status (≤ 80% of capacity) oscillated around 25% between 3 October 2019 and 16 March 2020 and then steeply increased to 80%, coinciding with the first wave of coronavirus disease 2019 (COVID‐19) cases in South Australia, which drove a major reduction in ED presentations (Box).5 The graph then shows a slow return to a baseline fluctuation of around 25% until January 2021. Since then, the moving average of EDs in “green” has been lower than 25%, showing an overall trend of increasing pressure over the subsequent months. This pattern is mirrored in the daily percentage of “red” and “white” status (ED at ≥ 95% of capacity). The 7‐day moving average of the daily percentage of EDs in “red” and “white” status exceeded 75% for the first time in February 2021. Four new record highs have been recorded since 10 May 2021, with the highest daily percentage of “red” and “white” observations at 98% on 27 May 2021. The average daily proportion of “red” and “white” observations pre‐pandemic (from 4 October 2019 to 19 March 2020) was 55% and has since increased to 64% (from 5 December 2020 to 29 June 2021), indicating that EDs are currently under significantly more strain. These issues are not new; EDs are one component of a complex interdependent health care system. EDs operating for extended periods at or near capacity is often the most conspicuous symptom of a broader system under pressure. It is doubtful that a solution to this problem can be found within the ED. Long term ED congestion relief lies in redesigning multiple aspects of the health and social care systems, which should involve health care consumer groups. Suggestions include: i) reducing hospital access block, ii) increasing social and community care, iii) adequate hospital beds, iv) alternatives to traditional care such as urgent care facilities or virtual wards, and v) cohort‐specific interventions to reduce ED presentations (eg, rehabilitation centres for alcohol and substance misuse). Box – Seven‐day moving average of the daily proportions of observations of the six metropolitan public hospitals (excluding the Women’s and Children’s Hospital) classified as alert codes “green” (0–80% occupied capacity), “amber” (80–95% occupied capacity), “red” (95–125% occupied capacity), and “white” (> 125% occupied capacity) between 4 November 2019 and 19 June 2021* * Due to problems in the data collection system, the data for the period between 14 and 31 July 2020 are missing.
Laura M Boyle · Mark Mackay · Keith Stockman
Unnecessary ultrasound imaging in the management of undescended testis
To the Editor: Undescended testis affects 2–4% of term male newborns.1 Clinical examination by an experienced clinician remains the most accurate method of assessing the position of the testis. It allows for the clear distinction between a retractile testis and palpable and impalpable undescended testes. In 2013, an evidence‐based statement on undescended testes was released jointly by Choosing Wisely and the American Urological Association which advocated against performing ultrasounds to investigate undescended testes due to their poor ability to localise non‐palpable testes.2 Unfortunately, this recommendation is not listed in the Australian Choosing Wisely website. Our study intended to improve awareness of the American Urological Association Choosing Wisely guidelines among Australian general practitioners and draw attention to the resources misspent due to lack of awareness. A retrospective audit was undertaken of 50 children referred in 2017 for an undescended testis to a single paediatric urologist in a private clinic. De‐identified data were extracted from the practitioner’s medical record system. The research ethics committee at the Sydney Adventist Hospital approved the publication of the audit. Of the patients referred with a diagnosis of an undescended testis, 35 testes (70%) were palpable in the scrotum on the day of consultation. However, 32 of 50 children (64%) already had an ultrasound by the time they were seen, with 51 testes (79%) labelled as undescended testis. Thus, more than two‐thirds of children had an ultrasound that was not needed, and the specificity was low at 27% (95% CI, 15–42%) (Box). About 159 379 boys were born in Australia in the study period.3 The cost of an ultrasound of the scrotum as per the Medicare Benefits Schedule was $109.50 (item 55048). Assuming an incidence of undescended testis of 2% and assuming ultrasounds were ordered in three times as many children, as happened in our study (15 undescended testes and 35 descended testes), the cost of unnecessary studies is calculated to be $1 047 120 (3 × 0.02 × birth cohort of 159 379 × $109.50). The numbers of Medicare claims for item 55048 have increased by 5% each year since 2010.4 Health budgets are finite, and expenditure should be linked to quality metrics. GPs and paediatricians are undoubtedly trying to be helpful by organising an ultrasound before the referral, but it is unnecessary. This letter is an attempt to continue the discussion with referring doctors to let them know that ultrasound is not required before referral for an undescended testis. This is a single clinic audit. We hope it will inspire larger population‐based audits to facilitate systemic change. Box – Ultrasound and examination findings Position of the testicle On examination inguinal On examination scrotal Total Inguinal ultrasound 16 35 51* Scrotal ultrasound 0 13 13 Total 16 48 64 * One testicle reported in the inguinal region on ultrasound was impalpable on examination.
Dharshini Selvarajah · Dermot McDowell · Susan Jehangir · Grahame Smith
Outcomes for patients with COVID‐19 admitted to Australian intensive care units during the first four months of the pandemic
To the Editor: Burrell and colleagues captured data from 77 hospitals containing 91% (n = 204) of coronavirus disease 2019 (COVID‐19) intensive care unit (ICU) cases during the first four months of the pandemic.1 Overall mortality (n = 30, 15%) for mechanically ventilated and non‐ventilated patients in this study was lower than other published data. In contrast, overseas reports have indicated mortality rates for patients with COVID‐19 admitted to ICUs of 40%, 44%, 60% and 70% in the United Kingdom, China, Italy and the United States, respectively.2 Evidence indicates that within developed countries, mortality rates associated with COVID‐19 vary according to physiological parameters but also markedly according to location.3 Low ICU bed occupancy and the distribution of cases across a large number of institutions1 has positively influenced Australian COVID‐19 mortality rates. Less obvious is the role and effect of critical care nurses. ICU nurse to patient ratios in Australian units were 1:1 and 2:1 for 77.8% and 7.5% of ICU days, respectively.1 Mortality is affected by local practice3 and in countries where ratios of 1:6 or more are common,2 mortality rates in ventilated patients can exceed 80%.4 Globally, point‐of‐care pandemic practice in ICUs has involved fewer critical care nurses, variously supported by redeployed nurses without critical care qualifications or experience. Critical care nurse expertise augments pre‐emptive rather than reactive strategies for ICU patient management. In the study by Burrell and colleagues, invasive ventilation was instituted for 119 (58%) patients: 79 (66%) of these on day 1, increasing to 94/113 (83%) by the end of week 1.1 Eighty‐five (42%) patients were able to be supported with either non‐invasive ventilation, high flow oxygen therapy or supplemental oxygen, monitored and managed by critical care nurses. Within an ICU model of care, critical care nurse staffing levels, skills mix, advanced practice functions and level of education ensure the high quality and safety of care delivery. Australian critical care nurses are expert clinicians with advanced education, training and experience who directly influence patient outcomes at the micro (patient and family), meso (unit or organisation) and macro (policy) level.5 Clearly elucidating workforce issues and composition is critically important for documenting models of care and associated outcomes in critical care.
Rochelle Wynne · Caleb Ferguson · Patricia M Davidson
Outcomes for patients with COVID‐19 admitted to Australian intensive care units during the first four months of the pandemic
In reply
Aidan JC Burrell · Tessa Broadley · Andrew A Udy
Absolute risk assessment for guiding cardiovascular risk management in a chest pain clinic
To the Editor: We read with interest the study by Black and colleagues1 on the effectiveness of a pro‐active risk factor management strategy based on absolute cardiovascular disease risk score compared with usual care, in a rapid access chest pain clinic setting. The study suggested that such a strategy significantly improved 5‐year cardiovascular risk scores; however, we would consider some caution before reaching such a conclusion. Although the authors point out several potential sources for bias in their study, there is an additional one that has not been highlighted. In the results, the authors state that “the increase in use of guideline‐based therapies was similar in the two groups,” yet do not go on to explain the differential effect as to why the blood pressure and lipid profiles decreased in the interventional group only. We suggest that the reason for this lies in a fundamental difference between the groups selected. The interventional group at baseline was receiving proportionately greater amounts of lipid‐lowering and anti‐hypertensive therapy: 56% and 30% higher, respectively, than in the control arm. These higher treatment rates may explain the lower blood pressure, the lipid profiles observed and, consequently, the improved final risk scores in the interventional arm. Also, as the authors pointed out, almost a third of eligible patients approached declined to participate and is therefore an important source of potential selection bias. We also note that the offer of referral to a public smoking cessation service was limited to those in the intervention group. National guidelines recommend this strategy as part of standard care,2 and hence we question whether this intervention should truly be considered to deviate from best practice or usual care.
Penni L Blazak · Kim Greaves
Absolute risk assessment for guiding cardiovascular risk management in a chest pain clinic
In reply
James A Black · James E Sharman · Thomas H Marwick
Sexual relationships between health practitioners and former patients
To the Editor: “Patients often suggest a ‘social meeting’ after you have treated them. It’s a slippery slope” — quote from an Australian medical student.1 A review published in The Medical Journal of Australia of what constitutes misconduct in health professional–former patient sexual relationships highlights the variation between different health professional codes and the repercussions.2 The article notes the lack of national guidance or codes of conduct for health professional students regarding this or similar professional boundary issues.2 The lack of knowledge on this and other professionalism dilemmas faced by students led to the Professionalism Opinions of Medical Students (PoMS) study.1 We obtained ethics approval from the University of Western Australia (Ref. RA/4/1/9278) to conduct the PoMs study using a mixed methods approach with a validated online survey1 to triangulate how the Australian public (n = 503), qualified doctors (n = 809), and medical students (n = 2602) viewed a range of professionalism dilemmas that medical students may encounter. Participation was voluntary and anonymous. Medical students were informed about the study through their medical school. Doctors and the public were informed about the study using media and social media resources. The surveys were closed when recruitment had plateaued. One of the scenarios asked for respondents’ opinions on how acceptable it would be for a medical student to embark on a romantic relationship with a former patient, and if student participants had encountered a similar situation. To determine whether unconscious bias influenced participants’ opinions, there were two randomly administered versions with female or male protagonists (no same‐sex version was included). The scenario is described below: A male/female medical student bumps into a 25‐year‐old woman/man at an evening concert. The student had taken her/his history and performed an abdominal examination in the emergency department a fortnight ago when she/he had attended with abdominal pain. The pair get chatting and the woman/man invites the student back to her/his flat for “somewhere quieter for a drink”. The male/female student accepts the invitation. How acceptable is this student’s behaviour? Almost 4% of medical student respondents (n = 84) reported encountering a situation similar to the one described. Using the χ2 test to compare the responses, there were significant differences in how the three demographic groups viewed this scenario. Notably, more than 50% of the public (n = 237), compared with more than 37% of the students (n = 896) and 29% of the doctors (n = 215) who completed this section of the survey considered this behaviour as acceptable (P < 0.001), regardless of the gender of the protagonist. Doctor participants were the only group to have no gender bias for the acceptability of the protagonist’s behaviour. Medical students’ opinions were intermediate, but were significantly influenced by their stage in the course. Survey participants in the early years of the medical course expressed opinions that aligned more with the public’s responses (478/1099, 43%), but the responses of students in the later years of the course were closer to the views expressed by qualified doctors as to how acceptable they considered the behaviour to be (412/1195, 34%; P < 0.01), supporting the concept of professional identity formation. The PoMS results demonstrate that medical students encounter patient sexual relationship dilemmas and are often unsure about how to manage this — a situation compounded by a lack of national guidance or codes of conduct. We endorse the suggestion that governing bodies provide clearer guidance to health professionals,2 but also advocate that health professional students are provided with explicit guidance on this and on how to apply the other behavioural expectations of good medical practice3 as a student.
Paul M McGurgan · Katrina L Calvert · Christine M Jorm
The absence of women involved in the criminal justice system from Australia’s national discussion on preventing family and domestic violence
To the Editor: The Standing Committee on Social Policy and Legal Affairs recently completed its inquiry and final report into family, domestic and sexual violence in Australia.1 This comprehensive report made 88 recommendations to inform Australia’s next National Plan to Reduce Violence Against Women and their Children (National Plan). The report explores violence victimisation in diverse communities (eg, Indigenous people, people with a disability). However, consideration of women involved in the criminal justice system is conspicuously absent. Many women involved in the criminal justice system are victim‐survivors of family, domestic and sexual violence. Estimates suggest that between 70% and 90% of women in prison in Australia have been victims of violence.2 In addition, our previous research found that women released from prison are 16 times more likely to die from violence compared with women of the same age in the Australian population.3 However, the only mention of women involved in the criminal justice system as victim‐survivors in the report is in the subsection discussing Indigenous people which acknowledges that Indigenous women experience disproportionate levels of violence victimisation and incarceration. While Indigenous women should be a priority group for violence prevention, and are over‐represented in prisons in Australia, this was a critical missed opportunity to address the over‐representation of victim‐survivors in the criminal justice system. For many Indigenous and non‐Indigenous women, their offending is connected to previous experiences of violence victimisation.2 Victim‐survivors are also being funnelled into the criminal justice system due to inappropriate criminal justice responses to family and domestic violence.4 As noted in the report, the current National Plan (2010–2022)5 has not been successful in reducing violence against women, and as such, this type of violence remains a prominent and all too common issue in Australia. Women involved in the criminal justice system should be among the priority groups for national violence prevention strategies. The next National Plan should address the health and social needs of these women, which are often drivers of both criminal justice involvement and violence victimisation (eg, mental health, housing, financial independence). Trauma‐informed criminal justice responses that recognise the impact of traumatic experiences on health and behaviour, such as pre‐arrest diversion to mental health or family violence services,6 are also needed. Without this, women who are victim‐survivors of violence will continue to be criminalised due to a misunderstanding of the impacts of family, domestic and sexual violence on their health, lives and behaviour.
Melissa Willoughby · Stuart A Kinner
Evidence and advocacy in Melbourne maternity care during the COVID‐19 pandemic
To the Editor: The average woman giving birth in Australia has ten to 12 antenatal visits and a 2–4 days inpatient stay, representing 8 months of intense engagement with health services. In 2020, women in Melbourne endured a prolonged lockdown period due to the coronavirus disease 2019 (COVID‐19) pandemic.1 During this time, the maternity sector had to move quickly to address three urgent priorities. Firstly, all 12 public maternity hospitals in Melbourne joined forces to create the Collaborative Maternity and Newborn Dashboard for the COVID‐19 pandemic (CoMaND) to meet the need for timely perinatal data collection.2 By harnessing hospital maternity data collection systems under a research protocol, they could centrally monitor perinatal outcomes to assess indirect impacts of the sector’s pandemic response (Box). The second of the priorities was to institute a system to record outcomes for women who were infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) during pregnancy. To this end, the Coronavirus Health Outcomes in Pregnancy and Newborns (CHOPAN) registry was established. It has collected information from 100 women with confirmed SARS‐CoV‐2 infection during pregnancy and has since expanded nationally (https://www.psanz.com.au/covid-19/). The third priority was to address the exclusion of pregnant women from COVID‐19 treatment trials, which occurred despite the fact that many of the investigational drugs had established pregnancy safety profiles.4 The Australasian COVID‐19 Trial (ASCOT) is an international multicentre randomised adaptive platform clinical trial of COVID‐19 therapies (https://www.ascot‐trial.edu.au). After representations from the maternity sector, a pregnancy ASCOT working group tasked with facilitating the safe inclusion of pregnant women was appointed, which established a welcome precedent for inclusion of pregnant women in future clinical research.5 The CoMaND and CHOPAN collaborations are exemplars of clinician‐led initiatives for data‐informed emergency responses in maternity care. It is anticipated that these resources will be of ongoing value into the COVID‐19 vaccination era. Successful advocacy for the inclusion of pregnant women in clinical trials may be another positive legacy of the COVID‐19 pandemic. Their safe inclusion in clinical trials takes us a step closer to an equitable health service, ensuring we generate a robust evidence base to direct clinical care for pregnant women and their children. Box – An example of outcome reporting from the fifth CoMaND report2 Denominator: number of singleton babies at ≥ 20 weeks’ gestation. Numerator: number of babies who meet the denominator criteria with birth weight ≥ 90th percentile adjusted for fetal sex and gestational age. Pre‐pandemic median: 8.75%. Significant shifts (≥ 6 weeks above the pre‐pandemic median) indicated with red arrows. Percentile source: Dobbins et al.3
Lisa Hui · Clare Whitehead · Susan P Walker
Screening for hydroxychloroquine retinopathy in Australia
To the Editor: We read with interest the perspective by Sonido and colleagues.1 We wish to highlight that Australian and New Zealand guidelines on screening for hydroxychloroquine retinopathy have been published by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO),2 written by a panel of retinal specialists in consultation with relevant medical disciplines. Key recommendations in the RANZCO guidelines include: baseline examination within the first year of hydroxychloroquine use; annual screening after 5 years of use for patients with no risk factors; and consideration of earlier review for patients at increased risk, such as those who receive hydroxychloroquine doses > 5 mg/kg/day; have renal impairment; use concurrent tamoxifen; have concomitant retinal or macular disease; or receive chloroquine.2 The guidelines recommend baseline examination within 1 year of beginning treatment to exclude concomitant retinal and macular disease, which may confound findings or add to the effects of hydroxychloroquine maculopathy.2 This contrasts with the recently updated United Kingdom guidelines, which do not recommend any form of screening in the first 5 years of treatment.3 The RANZCO minimum requirements for screening include dilated fundus examination, automated visual field testing, and spectral domain optical coherence tomography of the macula. Although automated macular visual field testing is appropriate in Caucasian patients, additional wider field testing is recommended in Asian patients to detect pericentral changes. Fundus autofluorescence and multifocal electroretinography are additional useful investigations and require interpretation by ophthalmologists trained in their interpretation. Patients who are found to have signs of retinopathy at screening or who have equivocal findings should be promptly referred for specialist ophthalmologist retinal assessment. Using the 2016 American Academy of Ophthalmology guidelines (comparable to the RANZCO guidelines), the cost‐utility of screening for hydroxychloroquine retinopathy was found to range from US$33 155 to $344 172 per quality‐adjusted life year.4 By reducing unnecessary screening in the first 5 years of dosing, we anticipate costs in the lower range per quality‐adjusted life year for screening using the RANZCO guidelines. Education of prescribers is necessary. United States studies show that 27% of patients are prescribed dosages exceeding current retinal guidelines,5 with significant non‐adherence to screening recommendations by both prescribers and patients. We encourage all prescribers of hydroxychloroquine to educate patients regarding screening, monitor for all complications, and report to the Therapeutic Goods Administration to obtain a comprehensive Australian dataset of all complications.
Adrian T Fung · Vicky Lu · Heather G Mack
Switching Australian patients with moderate to severe inflammatory bowel disease from originator to biosimilar infliximab
To the Editor: The SAME study affirmed the safety and efficacy of switching between originator and biosimilars and the potential for cost savings.1 Yet the global uptake of biosimilars has been relatively slow2 due to a number of factors, including marketing suggesting that such drugs are less safe or efficacious than the originator.3 Implicated in such marketing is confusion arising from the use of the word “interchangeable”, which is a defined term under United States legislation. The word “substitution” is used in Australia, which raises the likelihood of further confusion. Pfizer, which sponsors both biologics and biosimilars, petitioned the US Food and Drug Administration to avoid false and misleading statements about biosimilars.3 Key to Pfizer’s arguments is the definition of “interchangeability” in the Biologics Price Competition and Innovation Act of 2009 (US). To establish interchangeability, further clinical data are needed to show that switching a patient back and forth between the reference product and biosimilar “can be expected to produce the same clinical result as the reference product in any given patient [and] … the risk in terms of safety or diminished efficacy of alternating or switching … is not greater than the risk of using the reference product without such alternation or switch” (§ 262(k)(4)). This represents a higher threshold than biosimilarity, and there are currently no approved interchangeable biosimilars in the US, although a Bill (HR 8190) is currently being considered by the US Congress on insulin products. In Australia, case law has accepted the Therapeutic Goods Administration definition of a biosimilar as “a version of an already registered biological medicine” having “similar characteristics” to the biologic, with no explicit statement as to what “similar” means.4 If the sponsor of the originator were to claim that a competitor biosimilar is not interchangeable, although this would be correct in a legal sense, such claims could be misunderstood by Australian audiences as meaning that it is less safe or not therapeutically equivalent, even when it is “a‐flagged” and approved for pharmacist substitution.5 Therefore, it is important to distinguish the use of “interchangeability” and “substitution”, as these terms may be understood differently by doctors, pharmacists, other health professionals, and patients. Describing a biosimilar as (only) “similar” obscures the reality that approved biosimilars are as safe and efficacious as the originator. In such circumstances, a switch is appropriate, especially if it will save the patient and Pharmaceutical Benefits Scheme considerable money.
David Lim · Rhiannon Bandiera · Elizabeth Handsley
Switching Australian patients with moderate to severe inflammatory bowel disease from originator to biosimilar infliximab
In reply
Ashish Srinivasan · Craig Haifer · Lena Thin
Who is speaking for us? Identifying Aboriginal and Torres Strait Islander scholarship in health research
To the Editor: Australia is home to the oldest continuing cultures on Earth. Yet, rather than being treasured as a source of national pride, Aboriginal and Torres Strait Islander knowledges remain mostly unappreciated and, at times, actively silenced (eg, Uluru Statement).1 Passed down through generations, these valuable, continually changing knowledge systems are core to our adaptability, strength and survival against extreme adversity including colonisation. Persistent health disparities between Indigenous and other Australians signal the ineffectiveness of allegedly well intentioned policy and research that have largely produced deficit‐focused research, describing the extent of the Aboriginal and Torres Strait Islander problem rather than being driven by the priorities and solutions of Aboriginal and Torres Strait Islander communities. Institutions are now acknowledging that to close the gap in health disparities, “Aboriginal and Torres Strait Islander people must determine, drive and own the desired outcomes”.2 Gradual transformation in research governance and methodologies has occurred through ethics protocols and quality appraisal tools3 guiding the positioning of Aboriginal and Torres Strait Islander people as leaders and drivers of strengths‐based, benefit‐led research processes.4 Aboriginal and Torres Strait Islander researchers are more often leading the way in key health system domains, such as research ethics, education and effective community‐based research, but there is currently no systematic way of identifying our scholarship in the peer‐reviewed literature. How do we, as Aboriginal and Torres Strait Islander people, know who is representing, and speaking for, us? We assert the need to develop strategies to rectify and improve transparency of Indigenous health research. The first steps could be: inclusion of searchable tags for Indigenous authorship and contributorship (acknowledging non‐written contributions); for example, through extension of the Contributor Roles Taxonomy (CRediT), which is integrated into the Open Researcher and Contributor ID (ORCID; www.orcid.org) and used in over 120 journals;5 and expansion of contributor statements outlining diversity of roles and the positionality of our non‐Indigenous allies within the research. This would enhance the ability to efficiently distinguish Aboriginal and Torres Strait Islander scholarship, increasing the visibility of our knowledges and perspectives in research and translation, thereby improving the transparency of academic literature to guide decisions about our health and wellbeing. We seek the MJA’s leadership in “foregrounding Indigenous sovereignty”6 by advocating and appropriately acknowledging our contribution in health research.
Janine Mohamed · Veronica Matthews · Roxanne Bainbridge · Megan Williams
Non‐invasive prenatal testing: clinical utility and ethical concerns about recent advances
To the Editor: Thomas and colleagues1 describe the ethical complexities that can arise in the use of non‐invasive prenatal testing (NIPT) based on the detection of cell‐free fetal DNA in the maternal circulation to screen for chromosomal and other genetic fetal conditions, especially if the clinical utility and implications of the testing are not well understood and explained. They indicate that “the current NIPT tests available are for specific chromosomal aneuploidy, extended panels of targeted conditions and low resolution whole genome sequencing”. We support that all tests (for screening or diagnosis, and not just genetic tests) should be explained. However, we remind readers that there are specific tests using NIPT of cell‐free fetal DNA that have strong potential to benefit women and their fetuses and are at very low risk of the ethical hazards that concern Thomas and colleagues. A lead example is testing in women who are RhD (antigen) negative to predict whether the fetus is RHD (genotype) positive. Such testing can establish with a high level of certainty whether the fetus is RHD negative, in which case the woman can be spared the need for antenatal RhD immunoprophylaxis to prevent alloimmunisation. This approach not only spares around a third of women who are RhD‐negative the need for immunoprophylaxis but may also help reduce the burden on a small and altruistic pool of RhD immunoglobulin donors.2,3 In RhD‐negative women with preformed RhD antibodies, similar testing can be used to determine whether or not there is a need for intensive surveillance during the pregnancy for haemolytic disease of the fetus and newborn. To consider all tests that use NIPT based on cell‐free fetal DNA as carrying the same complexity of explanation and ethical risk would resemble a conclusion that all immunochemistry is ethically risky because of the difficulties of explaining and interpreting prostate‐specific antigen tests, or that all fetal ultrasound is unethical because in some countries it is used inappropriately for sex selection. We encourage readers to consider that the underlying reason and specific target for each test, much more than the platform on which it is run, determines the level of ethical complexity.
Helen G Liley · Michael J Peek · James Daly
Non‐invasive prenatal testing: clinical utility and ethical concerns about recent advances
To the Editor: The scope of genetic testing has advanced exponentially in the past 5–10 years and conversations between patients and clinicians are becoming more nuanced. This highlights the value of genetic professionals who are skilled at ensuring patients’ understanding of genetic testing to satisfy the legal requirements for consent.1,2 Other complexities in the setting of prenatal testing include finding of variants of uncertain significance, variable penetrance or expressivity associated with most genetic conditions, and potential future treatments for adult‐onset conditions uncovered by testing. Thomas and colleagues3 referred to power imbalance between a doctor and a patient as a factor that could ethically undermine consent for non‐invasive prenatal screening (NIPS). However, this power imbalance exists across all facets of medicine. Patients today are more medically savvy owing to easy access to information technology, thus reducing the knowledge gap (and the power imbalance). A doctor’s duty of care is to provide accurate and appropriate information that is understood by the patient in order to make a valid consent.2 There is no alternative to a valid consent for NIPS than one that is built upon an “I and thou” doctor–patient relationship.4 This relationship is a dynamic and shared experience, focusing not on the knowledge but on supporting expectant parents in making value‐consistent decisions.5 Uncertainties are not unique to NIPS; perinatal uncertainties are not new to either genetics or medicine, which can arise when a diagnosis is not made as well as when a diagnosis is made. Another ethical concern regarding NIPS is access and equity. As there is no Medicare funding for NIPS, should genetic disorders be screened out by the rich, would genetic conditions become the disease of the poor? This has implications for the society as a whole. Is there a duty to have a healthy child versus should we value diversity and disability? Would there be less social or medical support should society become less tolerant of individuals with disability? Genetics and other areas of medicine are evolving rapidly; nevertheless, the shared ethical considerations, including valid consent, uncertainty, and access equity, have remained to shape the moral principles of our society in this genomics era.
Alison McLean · Kathy Wu
Non‐invasive prenatal testing: clinical utility and ethical concerns about recent advances
In reply
Joseph Thomas · James Harraway · David Kirchhoffer
Australian recommendations for the management of hepatocellular carcinoma
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
Australian recommendations for the management of hepatocellular carcinoma
In reply
John S Lubel · Stuart K Roberts · Simone I Strasser · Nick Shackel
Greater scrutiny needed of alcohol companies’ use of brand extensions
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
Selection criteria for Australian and New Zealand medical specialist training programs: another under‐recognised driver of research waste
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
A hospital‐wide response to multiple outbreaks of COVID‐19 in health care workers: lessons learned from the field
To the Editor: We congratulate Buising and colleagues1 on their article published in the MJA and agree that the approach needs to be multidimensional and iterative. To expand upon the multidimensional theme of their article, we would like to emphasise the need for the approach to be multidisciplinary and to include the whole of the health service workforce. The article highlighted the ubiquitous nature of coronavirus disease 2019 (COVID‐19) transmission in health care settings, with 18.3% (or almost one in five) of health care workers infected, and that these workers are traditionally regarded as non‐clinical staff (food services, environmental services, administrative and security staff). The non‐clinician workforce has been overlooked in other research investigating COVID‐19 transmission risk factors.2 At Monash Health, we used multidisciplinary shift briefings to ensure all health service team members were included in the information and safety messages.3 Human factor‐designed briefing cards, based on the airline industry pre‐flight safety cards, were used to ensure consistent messaging (Box and online Supporting Information). The early involvement of a design team, from the Design Health Collab at Monash University, ensured clear and unambiguous messaging to health care workers. The images were designed to represent diversity in gender, race and role to ensure all health care workers would see themselves reflected in the briefing card and that the safety messages were relevant and directed towards them. Providing information that is timely and accessible as well as readable and visually clear is important.4 Commentaries have emphasised the need for clear and concise communication to ensure the safety and wellbeing of health care workers during the COVID‐19 pandemic.5 However, we believe that involving all workers, not just clinicians, in the safety messages and interventions is paramount to the health and safety of non‐clinical health care workers and to the ongoing operation of health care services. COVID‐19 does not recognise the individual worker role in the health care service and the pandemic has offered us a unique and powerful opportunity to bring together the whole health care workforce and break down traditional barriers. We believe that a multidisciplinary approach is just as vital as a multidimensional one. Box – Card used to ensure consistent messaging during shift briefings Permission to reproduce this image was obtained from the American Journal of Infection Control.
Diana Egerton-Warburton · Lisa Kuhn · Daphne Flynn
We need a model of health and aged care services that adequately supports Australians with dementia
To the Editor: Low and colleagues1 highlight the long‐standing issue that the provision of residential aged care in Australia remains grossly inadequate. This is particularly egregious given that these deficits and remedial actions have been known for decades from numerous inquiries commissioned by successive federal governments and reiterated by the Royal Commission. This vacuum is being filled by initiatives undertaken by the Victorian Government in public sector residential aged care services to develop better ways to conceptualise aged care. We acknowledge there is no single ideal model2 for the provision of residential aged care, as there is such wide variation in residential aged care services profiles (eg, number and type of residents, geographic location, physical environment, staffing). However, our recently proposed conceptual model for the provision of residential aged care3 includes many of the necessary aspects recommended by the NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. Our conceptual model takes as its purpose the provision of person‐centred care to older people with complex health issues, especially those living with dementia. It consists of five domains relevant to the experience of older people living in residential aged care: health care, social inclusion, individual rights, personal care and reablement, and dementia management. The model also supports the dignity of risk and quality of life beyond clinical care to enable older people to thrive. The development of our model involved several stages using a similar approach to model development described in 20104 which comprised: initial conceptualisation and development based on a review of the literature to document and map the key domains of residents’ needs in aged care; brainstorming using the expertise and experience of the research team to refine and categorise the domains and subdomains; extensive consultation with key stakeholders (n = 382) to test the model for feasibility and acceptability (field testing) for the sector; and testing against a range of theoretical organisational failure scenarios (validity checks against coroners’ cases). The model has been presented to the Royal Commission into Aged Care Quality and Safety and published in a peer‐reviewed journal.3 Uptake of this model would allow the Commonwealth government, which finances and regulates this sector, and individual service providers to have a common understanding of aged care. This is an important step towards improving aged care services.
Jo‐Anne Rayner · Deirdre Fetherstonhaugh · Joseph E Ibrahim
Challenges in delivering telemedicine to vulnerable populations: experiences of an addiction medical service during COVID‐19
To the Editor: Despite the rapid uptake of telemedicine during the coronavirus disease 2019 (COVID‐19) pandemic,1 it is important to identify the barriers that hinder the delivery of alternate modes of care among specific populations. We share our reflections on the challenges of implementing telemedicine in a tertiary addiction medical clinic in Melbourne, providing treatment for about 105 patients each month. At the start of the COVID‐19 pandemic in February 2020, videoconferencing appointments were encouraged, supported by technical assistance from a clinician. During the Stage 4 lockdown period (August to September 2020 inclusive), appointments were switched to videoconferencing, with face‐to‐face only offered where clinically necessary (eg, for long‐acting injectable opioid agonist treatment). For patients unable to access videoconferencing, telephone appointments were offered. The uptake of videoconferencing was low, comprising 21% (n = 47) of appointments conducted during lockdown versus 57% (n = 128) via telephone (Box). After the lockdown (November 2020 to February 2021), there was a gradual return to face‐to‐face appointments. Seven per cent (n = 28) of appointments were done via videoconferencing while 40% (n = 155) remained via telephone. Difficulties in connecting to the videoconferencing platform, poor audiovisual quality and time spent troubleshooting contributed to the low uptake of videoconferencing. While telemedicine has been a convenient mode of health care delivery during the COVID‐19 pandemic,3 not all patients benefit from it. People accessing specialist addiction treatment are often from sociodemographic groups that are digitally excluded, such as the unemployed and people with low income or with disabilities.4 We found several barriers to telemedicine in our patient cohort. Many patients did not own a computer, had poor digital literacy, could not afford internet access or did not have privacy for consultations. Telephone appointments raise clinical gaps, with physical signs, mental state and visual cues unable to be assessed. Digital inequality further marginalises an already vulnerable population. Access, affordability and digital ability issues need to be managed for telemedicine to be a viable option.4 Examples of how this might be achieved include the establishment of hubs with telemedicine facilities, technical support and private spaces, located at local community health centres for practicality and accessibility, along with providers offering more affordable internet plans for health care card holders. Box – Modality of clinic appointments by month during the coronavirus disease 2019 (COVID‐19)‐related restrictions in Melbourne, Victoria (total monthly COVID‐19 Victorian cases also shown2)
Anthony Hew · Shalini Arunogiri · Dan I Lubman
Recreational nitrous oxide misuse is resulting in serious neurological impairment and persistent disability among users
To the Editor: Published evidence recognises that the recreational misuse of nitrous oxide (N2O) can be associated with vitamin B12 deficiency and subacute combined degeneration of the spinal cord.1 Misuse of N2O is increasing,2 with canisters (known as “nangs” or “whippits”) readily available for legal purchase in convenience stores and online ostensibly for the purpose of whipping cream. In recent years, an increase in the number of emergency presentations and acute hospital admissions related to N2O misuse has been recorded in Australia.3,4 We have also seen an increase in the number of patients requiring specialist multidisciplinary rehabilitation for severe impairments, including proprioceptive deficits, ataxia, disabling lower limb weakness and persistent gait abnormalities. Over recent years, a growing number of patients have been admitted to our inpatient metropolitan Sydney rehabilitation unit with serious disabilities related to N2O misuse. In line with published reports, our experience confirmed that patients are often university students (typically aged < 30 years).3,4 As acute medical specialties recognise the significance of these presentations,3,4 we highlight that the resulting disabilities can remain for months or years at functional, vocational and emotional levels, and many will be lifelong. This will impose a significant disability burden that will require ongoing management by specialist rehabilitation and disability services and will have an impact on the wider health care utilisation and cost. As long as N2O remains legal and accessible and is perceived by many as seemingly innocuous, users will remain largely unaware of the severity and risk presented by its long term use. Compared with messaging surrounding other “hard drugs”, most of the literature and the public health messaging in Australia do not appear to emphasise the potential for catastrophic, permanent injury associated with the misuse of N2O. Given the emerging disability burden resulting from recreational N2O misuse, we recommend enhancing existing public awareness campaigns.5 We suggest that educational resources place greater emphasis on the potential for serious, long term impairments and that education campaigns be targeted to most susceptible people via tertiary and/or secondary education establishments. Widespread restrictions on N2O purchase should also be considered. Such measures may help prevent permanent and devastating disabilities resulting from the misuse of this easily accessible substance.
Simon Mosalski · Anne Tanner · Christine T Shiner
