Research

Objectives To evaluate the uptake of a new 60-day dispensing policy for antihypertensive medicines and estimated cost savings compared with conventional 30-day dispensing; and to explore general practitioner and pharmacist perspectives on the new policy. Study Design Mixed methods design; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing claims from 1 September 2023 to 30 April 2025; and semi-structured interviews with 20 general practitioners and four pharmacists from 13 June 2024 to 24 September 2024 to gauge their perspectives on 60-day dispensing. Setting, Participants General practitioners and pharmacists practising in New South Wales, Victoria and Queensland, Australia. Main Outcome Measure Antihypertensive prescription volumes; patient and government cost savings; and perceptions of the policy from general practitioners and pharmacists. Results The 60-day antihypertensive prescription volume increased from 75,500 to 877,700 over 20months, accounting for 21.2% of all antihypertensive dispensing by 30 April 2025. We estimate the total cost savings for patients were up to ~$65 million, and the government saved ~$87 million and paid pharmacies ~$86.7 million via the Additional Community Supply Support (ACSS) payment program, with a net effect of ~$0.3 million. In interviews, general practitioners indicated varied utilisation of 60-day prescriptions, with some actively providing 60-day prescriptions, but some rarely or not at all. Barriers included keeping abreast of eligible and ineligible medicines for 60-day prescriptions and perceived resistance from pharmacists. Pharmacists were concerned about incorrect dispensing and potential medication shortages. Conclusion At 20months after the introduction of the new policy, 21.2% of antihypertensive prescriptions were for 60-day dispensing. The slow uptake is likely due to low uptake among general practitioners and resistance from pharmacists. The 60-day policy has demonstrated substantial financial savings for patients. If uptake of 60-day dispensing increased to 50%, annual savings from antihypertensive medicines could rise to up to ~$165 million for patients and ~$11.6 million for the government.

Tian Wang, Huy L. Nguyen, Isabella Tan, Dean S. Picone, Emily Atkins, Sonali R. Gnanenthiran, Michael O. Falster, Sallie-Anne Pearson, Anthony Rodgers, Aletta E. Schutte

Elder abuse can lead to serious physical injuries and long-term psychological consequences, but its recognition and documentation in healthcare settings remain limited. This study used linked data from four Australian states to examine elder abuse coded during emergency department presentations and hospitalisations among 965,986 older people assessed for aged care services between 2010 and 2019. Only 580 people (0.06%) had elder abuse coded during an emergency department presentation or hospitalisation, highlighting substantial under-recognition and under-reporting in hospital settings.

Stephanie L. Harrison, Sahar Barmomanesh, Bryan Morden, Maria C. Inacio, Gillian E. Caughey, on behalf of the ROSA Consumer and Community Advisory Committee

Objective To explore primary care providers' perspectives on (i) healthcare needs and barriers to care for Aboriginal and Torres Strait Islander children and adolescents; and (ii) enablers and opportunities to strengthen care. Study Design A qualitative study; interviews and open-ended survey responses. Setting Primary care providers who work with Aboriginal and Torres Strait Islander children and young people in health and education settings in New South Wales and the Australian Capital Territory. Data were collected between 23 March 2022 and 13 October 2023. Main Outcome Measures Sixteen interviews and 33 open-ended survey responses were analysed using reflexive thematic analysis with a hybrid inductive/deductive approach. Results Participants reported that some of the most important health needs for children and young people related to mental health. They recognised that the presenting complaint was not always the underlying or only concern, demonstrated an understanding of trauma-informed care and acknowledged the importance of collaborative services that engaged support networks. Barriers to care included a lack of cultural safety in mainstream services, challenging social circumstances, financial concerns, being unaware of available services and privacy and confidentiality concerns. To improve care, staff identified several areas needing change including having a package of services tailored for young people; additional training for providers in child and adolescent health, particularly for mental healthcare, trauma-informed care and communication with young people; providing a safe and engaging environment; support for staff self-care; and additional resources. Conclusions Supporting mental health needs is a key aspect of caring for children and adolescents. To provide optimal primary healthcare, service providers require specialist skills. To support adolescents and children, participants identified a need for ongoing training, professional development and organisational support to ensure best practice care is sustained. This work has informed the development of training and other resources for partner health services.

Christianna Digenis, Rachel Reilly, Peter Azzopardi, Hilina Winkenweder, Odette Pearson, Kane Ellis, Jane Fisher, Debra J. Rickwood, Choong-Siew Yong, Ngiare Brown

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 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

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 assess the frequency of valproate prescribing for female patients of childbearing age at the Royal Children's Hospital, Melbourne, and to assess the frequency of documented discussions with these patients about the teratogenicity of valproate and the discussions or prescribing of contraception.Study DesignRetrospective audit of hospital electronic medical records data; analysis of Pharmaceutical Benefits Scheme (PBS) valproate dispensing data.Setting, Participants13- to 18-year-old girls or women prescribed valproate at the Royal Children's Hospital, Melbourne during 29 May 2022–29 May 2024; PBS valproate dispensing data for Australia for the 2023 calendar year.Main Outcome MeasuresCharacteristics of adolescent female patients prescribed valproate; documented discussions of valproate-related teratogenicity, and discussions or prescribing of contraception; population valproate prescribing rates for Australia and by state.ResultsValproate was prescribed for 245 female patients aged 13–18years during 2022–2024 (median age, 16years; interquartile range [IQR], 14–17years); the median prescribed daily dose was 600mg (IQR, 400–800mg; range, 200–2000mg). Valproate was prescribed for treating epilepsy for 221 patients (90%), including 97 (44%) with drug-resistant epilepsy; 160 patients (65%) had neurodevelopmental disabilities. Teratogenicity was discussed with 32 patients (13%), less frequently with patients with a neurodevelopmental disability (9% vs. 20%; odds ratio [OR], 0.41; 95% confidence interval [95% CI], 0.19–0.88). Contraception was discussed with 69 patients (28%); the proportion was larger for patients with neurodevelopmental disabilities (34% vs. 16%; OR, 2.66; 95% CI, 1.37–5.14). Contraception was prescribed for 50 patients (20%); the proportion was larger for patients with neurodevelopmental disabilities (25% vs. 12%; OR, 2.50; 95% CI, 1.18–5.30). The national PBS-subsidised dispensing rate during 2023 was 621 per 100,000 girls and women aged 13–18years; in Victoria it was 556 per 100,000 girls and women aged 13–18years.ConclusionDespite the risk of teratogenicity, valproate was prescribed for a considerable number of female adolescents at the Royal Children's Hospital during 2022–2024 and across Australia during 2023. Its teratogenicity was discussed with few patients, nor were discussions or prescribing contraception frequent. Contraception was more frequently discussed and prescribed for patients with neurodevelopmental disability, but teratogenicity was discussed less often.

Briana Davis, Monica S. Cooper, Michael South, Jeremy L. Freeman, Emma Macdonald-Laurs

ObjectivesTo determine whether ceasing acetylcysteine treatment for adults with acute paracetamol overdose after at least 12h of the two-bag acetylcysteine regimen is non-inferior to providing the full 20-h two-bag regimen.Study DesignOpen label, non-inferiority randomised controlled trial.SettingEmergency departments of six Australian metropolitan hospitals (four in Melbourne, two in Sydney), 1 December 2019–31 July 2024.ParticipantsAdults who required acetylcysteine treatment following single or staggered paracetamol ingestions whose serum alanine transaminase (ALT) level was below 40IU/L on presentation, and whose ALT levels were below 40IU/L and serum paracetamol concentrations below 20mg/L after 12 h of acetylcysteine treatment.InterventionControl group (standard care): two-bag intravenous acetylcysteine regimen (200mg/kg over 4h, followed by 100mg/kg over 16h). Intervention group: Acetylcysteine stopped at least 12h after treatment initiation and the 20-h infusion period completed with intravenous compound sodium lactate.Main Outcome MeasuresDifference in ALT level between presentation and 20h after acetylcysteine treatment initiation; non-inferiority was defined as the upper limit of the 95% confidence interval (CI) of the difference between median changes in ALT level for the intervention and control groups being less than 3IU/L.ResultsOf 2830 people who presented with paracetamol overdose, 860 received acetylcysteine treatment; 186 people who met both the presentation and 12-h acetylcysteine treatment blood test inclusion criteria (median age, 17years; interquartile range [IQR], 16–23years; 162 women [87%]) were randomly assigned to the intervention (93 participants) and control groups (93 participants). Median acetylcysteine infusion time in the intervention group was 13h (IQR, 13–13 h). The median change in ALT level between arrival and 20h after starting intravenous acetylcysteine treatment was similar for the intervention (−1IU/L; IQR, −4 to 1IU/L) and control groups (0IU/L; IQR, −2 to 2IU/L); the difference in median change (−1IU/L; 95% CI, −2 to 1IU/L) was consistent with the non-inferiority criterion. No patients developed hepatic injury or hepatotoxicity.ConclusionAn abbreviated acetylcysteine treatment regimen was non-inferior to the standard 20-h two-bag regimen for people with paracetamol overdose who were at low risk of hepatic failure.Trial RegistrationACTRN12619001549112 (prospective)

Anselm Wong, Richard McNulty, Sarah E. Hodgson, Naren Gunja, Andis Graudins

ObjectivesTo determine how many people who die of cancer in Victoria receive palliative care and early palliative care (more than 3months before death); to assess the impact of early palliative care on the quality of end-of-life care.Study DesignRetrospective, population-based cohort study; analysis of linked Victorian Cancer Registry data and routinely collected data for inpatient, non-admitted health service and emergency department care during the 12months prior to death.Setting, ParticipantsVictorian adults who died of cancer during 1 January 2018–31 January 2023.Main Outcome MeasuresProportions of people who received palliative care (any time) or early palliative care (more than 3months prior to death); likelihood of quality of end-of-life care measures: dying outside an acute hospital; chemotherapy, two or more emergency department visits, two or more hospital admissions during final 30days of life; advance care plan at death.ResultsOf 53,305 people who died of cancer (mean age, 74.8years [standard deviation, 13.0years]; 29,527 men [55.4%]), palliative care was provided for 38,697 (72.6%); 17,409 people (32.7%) received early palliative care. The most frequent palliative care type was palliative approach to care (Z51.5 code; 33,974 people, 63.7%). The overall proportion of people who received palliative care did not change markedly during 2018–2022; the proportion who received early palliative care declined slightly, from 34.8% (95% confidence interval [CI], 33.6–35.9) to 33.0% (95% CI, 31.7–33.8). People who received early palliative care were more likely than people who received late palliative care to have an advance care plan (adjusted odds ratio [aOR], 1.46; 95% CI, 1.38–1.55) and to die outside hospital (aOR, 2.50; 95% CI, 2.37–2.64); they were less likely to have two or more of emergency department presentations (aOR, 0.75; 95% CI, 0.70–0.81), two or more hospital admissions (aOR, 0.58; 95% CI, 0.55–0.61) or chemotherapy (aOR, 0.51; 95% CI, 0.47–0.55) during their final 30days of life.Conclusion72.6% of people who died of cancer in Victoria during 2018–2023 had received palliative care, but only 33% had received it early. End-of-life care may be improved by providing palliative care early. The low early palliative care rate, despite the potential for improved outcomes for people who receive it, indicates that action is needed.

Chris Schilling, Olivia Wawryk, Anna Collins, Vijaya Sundararajan, Brian H. Le, Jennifer Philip

Supporting general practitioners in the identification and management of endometriosis could reduce diagnostic delays and optimise clinical care

Danielle Mazza · Kailash Thapaliya · Sharinne B Crawford · Alissia Hui · Maryam Moradi · Luke E Grzeskowiak

By quantifying the impact of geographical disparities in cancer survival, these findings highlight the need for evidence-based interventions to improve cancer survival across Australia

Charlotte K Bainomugisa · Jessica Cameron · Paramita Dasgupta · Peter Baade

Aftercare for people who have poisoned themselves should include both mental health assessments and reviews of physical health conditions

Firouzeh Noghrehchi · Nicholas A Buckley · Rose Cairns