Research

Complementary medicines are used by more than half the people in Australia, incurring out‐of‐pocket health expenses of about $5.2 billion in 2019.1 Information about their use by older adults in Australia is more than a decade old.2 Given subsequent demographic changes and doubling in sales of vitamins and supplements,1 we should update our knowledge in this area. We analysed data from the ASPirin in Reducing Events in the Elderly (ASPREE) Longitudinal Study of Older Persons (ALSOP) to assess self‐reported use (every day, occasionally, never) of complementary medicines (fish oil, glucosamine, ginkgo, coenzyme Q10, calcium, zinc, vitamins B, C, D and E, multivitamins, Chinese or herbal) by healthy people over 70 years of age residing in metropolitan or regional Victoria, South Australia, Tasmania, the Australian Capital Territory or southern New South Wales, recruited through their usual general practitioners.3 We summarised data as descriptive statistics; we assessed differences between groups in χ2 tests (categorical variables). Analyses were conducted in SPSS Statistics 23 (IBM). ALSOP was approved by the Monash University Human Research Ethics Committee (reference, CF11/1100). During January 2012 – July 2015, 14 757 of 16 703 ASPREE participants returned ALSOP Baseline Medical Questionnaires3 with at least partial responses to the questions on complementary medicines (response rate, 88%); their mean age was 75.2 years (standard deviation, 4.3 years), and 8068 (55%) were women). A total of 10 961 respondents (74.3%) reported using them either daily or occasionally; fish oil (6563 of 14 757 respondents, 44.5%), vitamin D (4995, 33.8%), glucosamine (3940, 26.7%), and calcium supplements (3652, 24.7%) were the most frequently reported items (Supporting Information, table 1). Complementary medicines were used by larger proportions of women (6637 of 8068, 82.3%) than of men (4324 of 6689, 64.6%; P < 0.001), and of people with more than 12 years of education (4418 of 5838, 75.7%) than of people with less education (6542 of 8918, 73.3%; P = 0.001). The proportions of complementary medicine users who reported a history of depression (987 of 4053, 24.4%) or osteoarthritis (3060 of 5240, 58.4%) were larger than for non‐users (depression, 264 of 1347, 19.6%; P = 0.002; osteoarthritis, 705 of 1598, 44.1%; P < 0.001); self‐reported diabetes was more common among non‐users (363 of 3790, 9.6%) than among complementary medicine users (815 of 10 944, 7.4%; P < 0.001) (Box; Supporting Information, tables 2 and 3). Almost three‐quarters of people in our sample of community‐dwelling older adults in south‐eastern Australia used complementary medicines, with fish oil the most common product. While proprietary complementary medicines are generally regarded as safe, their widespread use by older people, who generally have a greater burden of disease, higher medical expenses, and low or fixed incomes, raises questions about their marketing and promotion.5 Our study population represents Australians over 70 who regularly visit general practitioners, and we included participants from geographically and socio‐economically diverse backgrounds.3 As we pre‐specified a limited number of products, our use estimates may be conservative. In our study, complementary medicine use was defined differently to some earlier studies; for example, the Australian Health Survey which asked about complementary medicine use in the previous 24‐hour period.6 This difference may account for our estimates being slightly higher. Our findings provide the most comprehensive information to date on complementary medicine use by Australians over 70 years of age. Box – Characteristics of respondents to survey of community‐dwelling Australians over 70 years of age on their use of complementary medicine

for the ALSOP Complementary Medicine Research Group*

Objectives: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. Design, setting, participants: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990–1999 and alive five years after diagnosis, with follow‐up to 31 December 2016. Main outcome measures: All‐cause and cancer cause‐specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow‐up period, and index cancer. Results: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow‐up time was 17 years (IQR, 11–21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non‐cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22–1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause‐specific deaths from 13 years after cancer diagnosis. Conclusions: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease‐related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease.

Bogda Koczwara · Rosie Meng · Michelle D Miller · Robyn A Clark · Billingsley Kaambwa · Tania Marin · Raechel A Damarell · David M Roder

The prognosis may not be as poor as overseas, but the intensive care resource burden may be greater

Aidan JC Burrell · Breanna Pellegrini · Farhad Salimi · Husna Begum · Tessa Broadley · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Arul Earnest · Simon J Erickson · Craig J French · John M Kaldor · Edward Litton · Srinivas Murthy · Richard E McAllister · Alistair D Nichol · Annamaria Palermo · Mark P Plummer · Mahesh Ramanan · Benjamin AJ Reddi · Claire Reynolds · Tony Trapani · Steve A Webb · Andrew A Udy

Switching trauma specialist services to pandemic management would be unwarranted

Teagan L Way · Seth M Tarrant · Zsolt J Balogh

Objectives: To assess whether the change from the Undergraduate Medical and Health Sciences Admissions Test (UMAT; 1991–2019) to the University Clinical Aptitude Test (UCAT) for the 2020 New South Wales undergraduate medical degree intake was associated with changes in the impact of sex, socio‐economic status and remoteness of residence, and professional coaching upon selection for interview. Design, setting, participants: Cross‐sectional study of applicants for the three NSW undergraduate medical programs for entry in 2019 (4114 applicants) or 2020 (4270); 703 people applied for both intakes. Applicants selected for interview were surveyed about whether they had received professional coaching for the selection test. Main outcome measures: Scores on the three sections of the UMAT (2019 entry cohort) and the five subtests of the UCAT (2020 entry); total UMAT and UCAT scores. Results: Mean scores for UMAT 1 and 3 and for all four UCAT cognitive subtests were higher for men than women; the differences were statistically significant after adjusting for age, socio‐economic status, and remoteness. The effect size for sex was 0.24 (95% CI, 0.18–0.30) for UMAT total score, 0.38 (95% CI, 0.32–0.44) for UCAT total score. For the 2020 intake, 2303 of 4270 applicants (53.9%) and 476 of 1074 interviewees (44.3%) were women. The effect size for socio‐economic status was 0.47 (95% CI, 0.39–0.54) for UMAT, 0.43 (95% CI, 0.35–0.50) for UCAT total score; the effect size for remoteness was 0.54 (95% CI, 0.45–0.63) for UMAT, 0.48 (95% CI, 0.39–0.58) for UCAT total score. The impact of professional coaching on UCAT performance was not statistically significant among those accepted for interview. Conclusions: Women and people from areas outside major cities or of lower socio‐economic status perform less well on the UCAT than other applicants. Reviewing the test and applicant quotas may be needed to achieve selection equity.

Barbara Griffin · Graeme L Horton · Lisa Lampe · Boaz Shulruf · Wendy Hu

In Australia, colorectal cancer is the second most frequently diagnosed cancer and one of the most common causes of cancer‐related death.1 Evidence that bowel cancer screening reduces mortality through early detection and treatment2 led to the introduction in 2006 of the Australian National Bowel Cancer Screening Program (NBCSP), offering faecal occult blood testing. The NBCSP has been progressively rolled out, from covering those aged 55 or 65 years in 2006 to screening every two years for all Australians aged 50–74 years by 2020.3 During 2016–17, 41% of people invited to participate in screening did so.4 A recent review of the NBCSP found that the risk of death from colorectal cancer was lower for invitees, and that those who had cancer were diagnosed at an earlier stage of disease.5 In Australia, jurisdictional cancer registries do not collect data on surgery‐related morbidity. However, the Binational Colorectal Cancer Audit (BCCA) (https://www.bowelcanceraudit.com) has collected information since 2007 on the diagnosis, management, and outcomes of surgically managed Australian and New Zealand patients with colorectal cancer, as well as whether patients were identified by the NBCSP. BCCA data are voluntarily collected by 435 registered surgeons at 138 participating hospitals across Australia and New Zealand, covering about 24% of newly diagnosed cases of colorectal cancer in 2019.6 We sought to determine whether patients with surgically managed colorectal cancer diagnosed through the NBCSP have better post‐operative outcomes than those diagnosed in other pathways. We undertook a cross‐sectional analysis of de‐identified BCCA data for patients aged 18 years or over who underwent surgery in Australia for colorectal cancer during January 2007 – December 2018. Outcome measures were inpatient and 30‐day mortality; surgical complications; medical complications; return to theatre; and hospital length of stay. We undertook binary logistic regression to assess associations between screening and binary outcomes. The association with length of stay was assessed in ordinary least squares linear regression models. The Monash University Human Research Ethics Committee (project, 19327) and the BCCA Operations Committee provided ethics approval for our study. Of 23 310 cases of colorectal cancer in the database, we could include 15 630 cases with data on cancer type and screening status in our comparison of demographic and clinical characteristics. A larger proportion of patients identified by the NBSCP than of otherwise identified patients were men (58% v 54%); their mean age (64 years, standard deviation [SD], 7 years v 69 years; SD, 14 years) was lower, and larger proportions had American Society of Anesthesiologists (ASA) scores in the low risk range (77% v 59%), were from lower socio‐economic status areas, had presented for elective surgery (96% v 85%), had less advanced cancer stage disease (stages 0–II: 69% v 63%), and underwent minimally invasive surgery (80% v 66%) (Box 1). Data on adjusting variables and outcomes were available for the 11 366 cases included in our logistic regression models. NBSCP‐detected patients were less likely to have post‐operative surgical (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.69–0.99) or medical complications (aOR, 0.75; 95% CI, 0.59–0.94); their length of stay was also briefer (adjusted mean difference, –1.56 days; 95% CI, –2.06 to –1.06 days). Post‐operative mortality and return to theatre rates were similar for screened and other patients (Box 2). Our analysis of BCCA data indicates that, in addition to the lower long term mortality associated with the NBCSP,5 short term post‐operative benefits are also evident that should be taken into account when promoting the program. Our study reinforces calls to improve participation rates in the national screening program by eligible participants to optimise the value of this critically important initiative. Box 1 – Demographic and clinical features of 15 730 patients who underwent surgery for colorectal cancer in Australia, 2007–2018, by diagnostic pathway Identification of patients Characteristic Total NBSCP Other P Number of patients 15 730 1357 14 373 Age at surgery (years) Mean (SD) 69 (13) 64 (7) 69 (14) < 0.001 Range 18–100 50–75 18–100 50 or under* 1556 (10%) 77 (6%) 1479 (10%) 51–60 2433 (15%) 385 (28%) 2048 (14%) 61–70 4192 (27%) 651 (48%) 3541 (25%) 71–80 4473 (28%) 244 (18%) 4229 (29%) over 80 3073 (20%) 0 3073 (21%) Missing data 3 0 3 Sex 0.003 Women 7142 (45%) 563 (42%) 6579 (46%) Men 8586 (55%) 792 (58%) 7794 (54%) Missing data 2 2 0 American Society of Anesthesiologists score < 0.001 1–2 (low risk) 9205 (60%) 1000 (77%) 8205 (59%) 3–5 (high risk) 6033 (40%) 294 (23%) 5739 (41%) Missing data 492 63 429 Socio‐economic status (IRSD quintile) < 0.001 1 (most disadvantaged) 2470 (16%) 224 (17%) 2246 (16%) 2 2385 (16%) 221 (17%) 2164 (16%) 3 2957 (20%) 278 (22%) 2679 (19%) 4 3107 (21%) 288 (22%) 2819 (20%) 5 (least disadvantaged) 4153 (28%) 282 (22%) 3871 (28%) Missing data 658 64 594 Cancer type 0.50 Colon 11 287 (72%) 963 (71%) 10 324 (72%) Rectal 4443 (28%) 394 (29%) 4049 (28%) Operative urgency < 0.001 Elective 13 457 (86%) 1310 (96%) 12 147 (85%) Emergency 999 (6%) 11 (1%) 988 (7%) Urgent 1248 (8%) 36 (2%) 1212 (8%) Missing data 26 0 26 Cancer stage < 0.001 0 (cancer in situ) 699 (5%) 92 (7%) 607 (4%) I (local disease) 3728 (24%) 535 (41%) 3193 (23%) II (local disease) 4689 (31%) 278 (21%) 4411 (32%) III (nodal spread) 4437 (29%) 347 (26%) 4090 (29%) IV (metastatic disease) 1625 (11%) 42 (3%) 1583 (11%) X (not identifiable) 121 (1%) 16 (1%) 105 (1%) Missing data 431 47 384 Operative approach < 0.001 Minimally invasive surgery† 10 498 (67%) 1082 (80%) 9416 (66%) Open 5140 (33%) 269 (20%) 4871 (34%) Missing data 92 6 86 IRSD = Index of Relative Socioeconomic Disadvantage (Australian Bureau of Statistics); NBSCP = National Bowel Cancer Screening Program; SD = standard deviation. * National screening program participants are aged 50 years or more. † Laparoscopic, hybrid, conversion of laparoscopic, robotic and transanal total mesorectal excision. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Logistic and linear regression analysis of the association between screening and outcomes for 11 366 patients with colorectal cancer, Australia, 2007–2018 Identification of patients NBSCP v other Outcome NBSCP Other Univariate regression: OR (95% CI) Multivariate regression: aOR* (95% CI) Number of patients 843 10 523 30‐day mortality† 2 175 0.14 (0.02–0.44) 0.31 (0.05–1.01) Surgical complications‡ 171 2494 0.82 (0.69–0.97) 0.83 (0.69–0.99) Medical complications§ 89 1889 0.54 (0.43–0.67) 0.75 (0.59–0.94) Returned to theatre 52 658 0.99 (0.73–1.31) 1.02 (0.75–1.37) Mean difference (95% CI) Adjusted mean difference* (95% CI) Length of stay (days), mean (SD) 7.27 (6.17) 9.62 (8.02) –2.34 (–2.90 to –1.79) –1.56 (–2.06 to –1.06) aOR = adjusted odds ratio; CI = confidence interval; NBSCP = National Bowel Cancer Screening Program; OR = odds ratio; SD = standard deviation. * Adjusted for age, sex, socio‐economic status, screen category, cancer type, American Society of Anesthesiologists score. † Within 30 days of surgery. ‡ Abdominal/pelvic collection, anastomotic leak, entero‐cutaneous fistula, wound dehiscence, wound infection, sepsis, ileus, small bowel obstruction, urinary retention, ureteric injury, splenectomy, post‐operative haemorrhage. § Including chest infection, cardiac complications, deep vein thrombosis, pulmonary embolus.

Sasha Taylor · Farhad Salimi · Arul Earnest · Alexander G Heriot · John R Zalcberg · Susannah Ahern

Objective: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. Design: Retrospective analysis of National Coronial Information System (NCIS) data. Setting, participants: People aged 10–24 years who died by suicide in Australia during 2006–2015. Main outcome measures: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. Results: 3365 young people died of suicide during 2006–2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio‐economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self‐harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). Conclusions: Three‐quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

Nicole TM Hill · Katrina Witt · Gowri Rajaram · Patrick D McGorry · Jo Robinson

The incidence of colorectal cancer in Australia is among the highest in the world.1 About 29% of Australians live in rural or remote areas. We have previously reported that colorectal cancer surgery in rural hospitals is safe and that short term outcomes are good.2 This report is based on prospectively collected data for 311 patients treated for stages 1 to 3 colorectal cancer by four surgeons in rural South Australia (Mount Gambier Hospital, with 110 beds and a six‐bed high dependency unit) during 1 February 2006 – 31 January 2020. The follow‐up parameters, intervals between follow‐up examinations, and data analysis tools have been reported previously.2 Briefly, data were analysed in SigmaStat 3.5 (Systat). Survival was analysed by single‐group and log‐rank testing; survival differences between groups were assessed by pairwise multiple comparison (Holm–Šídák). Group data were compared in t, rank sum, and χ2 tests; correlations of covariates and cancer‐specific survival were assessed by multiple logistic regression. The Central Adelaide Local Health Network Human Research Ethics Committee approved our study (reference, 12041). One hundred of 311 patients (32%) had Union for International Cancer Control (UICC) stage 1, 110 (35%) stage 2, and 101 (33%) stage 3 colorectal cancer. The median age of the patients was 71 years (interquartile range [IQR], 63–78 years); 172 (55%) were men. Of the 311 procedures, 277 were elective (89%); 113 were laparoscopic (36%) and 198 laparotomies (64%). Median hospital length of stay was 7 days (IQR, 4–10 days); 30‐day mortality was 1.3% (four deaths), 90‐day mortality 1.6% (five deaths). The proportion of deaths at 30 days after emergency colorectal cancer surgery (three of 34 patients, 9%) was significantly greater than following elective surgery (one of 277, 0.4%; P = 0.002). Leakage occurred in 13 of 259 procedures with anastomosis (5%). The median number of lymph nodes resected was 14 (IQR, 10–20). Overall 5‐year survival of patients (stages 1–3) was 79%, 10‐year survival was 45%. Cancer‐specific 5‐year survival was 86% and 10‐year survival 79% (Box). Multivariate analysis included patient sex, age, intra‐operative blood loss, laparoscopic surgery, American Society of Anesthesiologists (ASA) score, and UICC stage as covariates. More advanced tumour stage (stages 1/2 v stage 3: odds ratio [OR], 2.01; 95% confidence interval [CI], 1.39–2.90) and higher age (< 70 years v ≥ 70 years: OR, 2.28; 95% CI, 1.11–4.71) were significantly associated with lower overall survival. Cancer‐specific survival was significantly reduced by more advanced tumour stage stages 1/2 v stage 3: OR, 4.76; 95% CI, 2.53–8.94). Our follow‐up program included quarterly blood tests (carcino‐embryogenic antigen, carbohydrate antigen 19.9, full blood cell count) and clinical examination during the first two years, semi‐annual tests during the next three years, and annual blood tests and clinical examinations thereafter. Throughout follow‐up, annual computed tomography and colonoscopy were offered to all patients, and additional investigations initiated in response to changes in clinical or laboratory findings. This intense follow‐up program, based on that used at the University of Munich in Germany, was adopted when the current surgical unit was established in Mount Gambier. It is being reviewed and will be adjusted to current Australian recommendations. Recurrent disease was detected in a total of 52 patients (17%), and 13 patients (4%) underwent curative resection. The primary treatment for colorectal cancer is surgical removal. Surgical care should be provided in an adequately staffed and equipped hospital. We found that such surgery can be provided safely and with good long term oncological outcomes in a rural centre. Overall 5‐year survival in our study exceeded the most recent reported value for Australia (2011–2015: 69.9%),3 and contrasts with a Californian study which found that rural residence was associated with poorer cancer‐specific mortality.4 Published data on outcomes beyond 10 years after colorectal cancer surgery are limited. Our overall 10‐year survival rate of 45% is similar to that reported by an earlier study in Fremantle (44%).5 Our findings confirm that tumour stage and age at diagnosis are significant predictors of death following curative surgery for colorectal cancer. We found that colorectal cancer surgery in a non‐metropolitan surgical centre is safe and associated with low 30‐ and 90‐day mortality rates. Oncological results at 5 and 10 years compare well with the results of other groups. Surgery can be provided close to the patients’ homes and families in adequately staffed and equipped centres and can match outcomes in capital city hospitals. Box – Five‐ and 10‐year survival of patients undergoing curative resection for colorectal cancer at Mount Gambier Hospital, February 2006 – January 2020 5‐year survival 10‐year survival Overall Cancer‐specific Overall Cancer‐specific All 79% 86% 45% 79% Union for International Cancer Control (UICC) stage Stage 1 (pT1/pT2) 91% 99% 58% 99% Stage 2 (pT3/pT4) 82% 87% 51% 85% Stage 3 (any T, node positive) 55% 74% 39% 55% American Society of Anesthesiologists (ASA) physical status classification 1 100% — 100% — 2 84% — 58% — 3 70% — 32% — 4 62% — 0 — Age < 70 years 86% — 72% — 70–79 years 76% — 32% — ≥ 80 years 60% — 7% — pT = primary tumour staging. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; }

Matthias W Wichmann · Timothy K McCullough · Eben Beukes · Thomas Gunning · Guy J Maddern

Objective: To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. Design, setting, participants: Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 – Nov 2018) about their experience of unprofessional behaviours — 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) — and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking‐up skills. Main outcome measures: Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self‐reported speaking‐up skills. Results: Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9–94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5–40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6–15.5%) reported extreme unprofessional behaviour. Nurses and non‐clinical staff members aged 25–34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self‐reported speaking‐up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46–0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67–0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38–0.51). Conclusions: Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

Johanna Westbrook · Neroli Sunderland · Ling Li · Alain Koyama · Ryan McMullan · Rachel Urwin · Kate Churruca · Melissa T Baysari · Catherine Jones · Erwin Loh · Elizabeth C McInnes · Sandy Middleton · Jeffrey Braithwaite

A public mental health response that includes universal, selective and indicated clinical interventions is needed

Jane RW Fisher · Thach D Tran · Karin Hammarberg · Jayagowri Sastry · Hau Nguyen · Heather Rowe · Sally Popplestone · Ruby Stocker · Claire Stubber · Maggie Kirkman

Social restrictions reduced the spread of COVID-19 within 14 days of measurable changes in public mobility

Tu Hao Tran · Suraj N Sasikumar · Annemarie Hennessy · Aiden O'Loughlin · Lucy Morgan

Hospitals in the Northern Territory often operate beyond capacity and serve a sparsely distributed population with rates of chronic disease and household overcrowding that are higher than in many other parts of Australia. The NT consequently adopted particularly strict public health measures to avert the potentially catastrophic consequences of community transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), including supervised isolation until viral clearance of all people with confirmed SARS‐CoV‐2 infections (Supporting Information 1). This measure provided a unique opportunity to study the duration and trajectory of viral shedding in relation to clinical illness. In this article, we describe epidemiologic, clinical, and virological aspects of the first 28 cases of coronavirus disease 2019 (COVID‐19) in the NT. The Top End and Central Australian Human Research Ethics Committees approved the study (reference, 2020‐3737). Between 4 March and 4 April 2020, 28 cases of COVID‐19 were diagnosed in the NT, all linked to overseas or interstate travel. The median age of patients was 45.0 years (range, 1.5–75 years); 16 were women (Supporting Information 1, table). Two patients required supplemental oxygen, one of whom also required intubation. There were no deaths. Symptoms had been present for a median 3 days (range, 0–16 days) before oro‐nasopharyngeal swab collection and lasted a median 9.5 days (range, 4–18 days). Viral RNA could be detected by multiplex tandem real‐time polymerase chain reaction (PCR) assay (AusDiagnostics; Supporting Information 1) for a median 25 days after symptom onset (range, 14–41 days; interquartile range [IQR], 21–32 days), and in most patients for more than two weeks after symptom resolution (median, 17.5 days; range, 2–31 days; IQR, 14.5–22.5 days) (Box 1). Within‐patient variability in viral target cycle threshold values during follow‐up was considerable (Box 2; Supporting Information 1, figure), despite adequate and consistent amounts of human biologic material in test samples (data not shown). Prolonged compulsory isolation was distressing for several patients. The phylogeny of the 27 available NT viral genomes was consistent with acquisition in locations on all inhabited continents (Box 3). Five genetic clusters were evident (maximum of one single nucleotide polymorphism within each cluster) that were also epidemiologically linked by shared travel or household contact. The SARS‐CoV‐2 genomes from two independent travellers without epidemiologic connections were identical, but matched other publicly available genomes, highlighting the importance of interpreting genomic analyses in their epidemiologic context. The priority of the strict NT isolation requirements for patients with COVID‐19 was viral containment at a time when data on the duration of viral transmissibility were sparse. More recent evidence suggests that viable SARS‐CoV‐2 is rarely isolated more than 10 days after symptom onset,1,2,3 and requirements have consequently been eased, while maintaining supervised isolation with health management during the period of greatest infectivity. The high degree of temporal variability in viral shedding during follow‐up indicates that a single assay is not adequate for excluding infection in patients at epidemiologic risk of COVID‐19. The NT implemented particularly aggressive public health measures to contain SARS‐CoV‐2 transmission. Epidemiologic and genomic analyses suggest that this response has successfully prevented local community transmission of the virus. Box 1 – Time course of 28 cases of coronavirus disease 2019 (COVID‐19) diagnosed in the Northern Territory, 4 March – 4 April 2020 Each line represents a single patient. Day zero is the day of collection of the first SARS‐CoV‐2‐positive specimen; thickened sections indicate the period of COVID‐19 symptoms. Closed circles indicate positive SARS‐CoV‐2 assay results, hollow circles negative assay results. Patients 13 and 15 (lighter marking) required supplemental oxygen. The bottom line summarises the median duration of symptoms prior to diagnosis, the median duration of symptoms, and the median time to viral clearance. Box 2 – Multiplex tandem polymerase chain reaction cycle threshold values for detection of the SARS‐CoV‐2 open reading frame 1a gene (ORF1a) Box 3 – Maximum likelihood phylogenetic tree, depicting SARS‐CoV‐2 genomes from the Northern Territory and elsewhere SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. The phylogenetic tree shows that SARS‐CoV‐2 genomes in the Northern Territory (on the inner side of the outer ring) were drawn from across the range of genomes reported elsewhere (outer ring). NT travel‐related cases with epidemiologic links formed genomic clusters. Two cases without epidemiologic links also comprised a cluster, but the genomes were identical with overseas genomes. The context genomes were obtained from GISAID (https://www.gisaid.org), with region based on location of the submitting laboratory; the Wuhan‐Hu‐1 genome was used as an outgroup, and the scale bar indicates substitutions per site.

for the Northern Territory COVID‐19 Response Group

Objective: To examine whether non‐medical switching of patients with inflammatory bowel disease (IBD) from originator infliximab to a biosimilar (CT‐P13, Inflectra) is safe and clinically non‐inferior to continued treatment with originator infliximab. Design: Prospective, open label, multicentre, parallel cohort, non‐inferiority study in seven Australian hospitals over 48 weeks, May 2017 – October 2019. Participants: Adults (18 years or older) with IBD receiving maintenance originator infliximab (Remicade) who had been in steroid‐free clinical remission for at least 12 weeks. Intervention: Managed program for switching patients in four hospitals from originator to biosimilar infliximab (CT‐P13); patients in three other hospitals continued to receive originator infliximab (control). Main outcome measures: Clinical disease worsening requiring infliximab dose escalation or change in therapy. Results: The switch group included 204 patients, the control group 141 patients with IBD. Ten patients in the control group (7%) and 16 patients switched to CT‐P13 (8%) experienced clinical deterioration; the adjusted risk difference (control v switch group) was –1.1 percentage points (95% CI, –6.1 to 8.2 percentage points), within our pre‐specified non‐inferiority margin of 15 percentage points. Serious adverse events leading to infliximab discontinuation were infrequent in both the switch (six, 3%) and control (six, 4%) groups. Conclusion: Switching patients with IBD from originator to biosimilar infliximab is safe and non‐inferior to continuing treatment with originator infliximab. Moreover, the introduction of biosimilar infliximab, by increasing market competition, has resulted in substantial cost savings for the Pharmaceutical Benefits Scheme.

Craig Haifer · Ashish Srinivasan · Yoon‐Kyo An · Sherman Picardo · Daniel Langenberg · Shankar Menon · Jakob Begun · Simon Ghaly · Lena Thin

Objectives: To evaluate whether educating junior doctors and hospital pharmacists about analgesic prescribing improved discharge prescribing of opioids for opioid‐naïve patients after surgical admissions. Design: Cluster randomised controlled trial, undertaken during the first half of 2019. Setting: The Alfred Hospital, a major Melbourne teaching hospital with 13 surgical units. Participants: Opioid‐naïve patients discharged from surgical units after a stay of at least 24 hours. Intervention: Surgical units were randomised to the intervention or control arms. Interns, residents, and clinical pharmacists assigned to intervention arm units attended education sessions, presented by the hospital analgesic stewardship pharmacist, about appropriate analgesic prescribing for patients in hospital surgical units. Main outcome measures: The patients prescribed slow release opioids on discharge from hospital during the baseline (1 February – 30 April 2018) and post‐intervention periods (17 February – 30 April 2019). Results: During the baseline period, 1369 intervention unit and 1014 control unit admissions were included in our analysis; during the evaluation period, 973 intervention unit and 706 control unit episodes were included. After adjusting for age, length of stay, pain score, acute pain service involvement, and use of immediate release opioids prior to admission, patients in the intervention group were prescribed slow release opioids at discharge less frequently than patients in the control group (adjusted odds ratio [aOR], 0.52; 95% CI, 0.35–0.77) and were more frequently discharged without any prescribed opioids following the intervention (aOR, 1.69; 95% CI, 1.24–2.30). Providing de‐escalation plans was more frequent for intervention than control group patients prescribed slow release opioids on discharge post‐intervention (OR, 2.36; 95% CI, 1.25–4.45). Conclusions: Specific education for clinicians and pharmacists about appropriate analgesic prescribing for surgical patients is effective in reducing prescribing of opioids at discharge. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000876291 (prospective).

Ria E Hopkins · Thuy Bui · Alex H Konstantatos · Carolyn Arnold · Dianna J Magliano · Danny Liew · Michael J Dooley

Objective: To assess long term graft and patient survival after donor liver retransplantation in children in Australia and New Zealand during 1986–2017; to determine the factors that influence survival. Design: Retrospective cohort analysis (registry data). Setting, participants: Australia and New Zealand Liver Transplant Registry data for all liver retransplantations in children (under 18 years of age), 1986–2017, in all four paediatric and six adult liver transplantation centres in the two countries. Main outcome measures: Graft and patient survival at one, 5, 10 and 15 years. Results: 142 liver retransplantations were undertaken in children (59 during 1986–2000, 83 during 2001–2017). Kaplan–Meier survival analysis indicated that survival was significantly greater during 2001–2017 than 1986–2000 (P < 0.001). During 2001–2017, graft survival one year after retransplantation was 84%, at 5 years 75%, at 10 years 70%, and at 15 years 54%; patient survival was 89% at one year, 87% at 5 years, 87% at 10 years, and 71% at 15 years. Median time between transplantations was 0.2 years (IQR, 0.03–1.4 years) during 1986–2000, and 1.8 years (IQR, 0.1–6.8 years) during 2001–2017 (P = 0.002). The proportion of graft failures that involved split grafts was larger during 2001–2017 (35 of 83, 42%) than 1986–2000 (10 of 59, 17%). Graft type, cause of graft failure, and number of transplants did not influence survival following retransplantation. Conclusion: Survival for children following retransplantation is excellent. Graft survival is similar for split and whole grafts. Children on the liver waiting list requiring retransplantation should have the same access to donor grafts as children requiring a first transplant.

Angus W Jeffrey · Gary P Jeffrey · Michael Stormon · Gordon Thomas · Edward O'Loughlin · Albert Shun · Winita Hardikar · Robert Jones · John McCall · Helen Evans · Graham Starkey · Peter Hodgkinson · Looi C Ee · David Moore · Catherine Mews · Geoff W McCaughan · Peter W Angus · Alan J Wigg · Michael Crawford · Jonathan Fawcett

Objective: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design: Retrospective analysis of Victorian Cancer Registry data linked to population‐based administrative health datasets. Setting, participants: 29 325 Victorian men diagnosed with prostate cancer during 2011–2017. Main outcome measures: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31–1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13–2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42–0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011–2017 for men with ISUP grade 1 disease, but not ISUP grade 2–5 tumours. Conclusion: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Luc te Marvelde · Roger L Milne · Colin J Hornby · Adam B Chapman · Graham G Giles · Ian E Haines

Overcoming patient, GP, and health system barriers to changes in care delivery are critical to progress

Charlotte M Hespe · Anna Campain · Ruth Webster · Anushka Patel · Lucie Rychetnik · Mark F Harris · David P Peiris

Objectives: To assess catch‐up vaccination of older children and adolescents during the first two years of the “No jab, no pay” policy linking eligibility for federal family assistance payments with childhood vaccination status. Design, setting, participants: Cross‐sectional analysis of Australian Immunisation Register data on catch‐up vaccination of children aged 5 to less than 7 years before (January 2013 – December 2014; baseline) and during the first two years of “No jab, no pay” (December 2015 – December 2017), and of children aged 7 to less than 10 years and young people aged 10 to less than 20 years (“No jab, no pay” period only). Main outcomes: Catch‐up vaccination rates for measles–mumps–rubella vaccine second dose (MMR2), by age group, Indigenous status, and socio‐economic status; catch‐up vaccination of children aged 5 to less than 7 years (third dose of diphtheria–tetanus–pertussis vaccine [DTPa3], MMR1), before and after introduction of “No jab, no pay”. Results: The proportion of incompletely vaccinated children aged 5 to less than 7 years who received catch‐up DTPa3 was higher under “No jab, no pay” than during the baseline period (15.5% v 9.4%). Of 407 332 incompletely vaccinated people aged 10 to less than 20 years, 71 502 (17.6%) received catch‐up MMR2 during the first two years of “No jab, no pay”, increasing overall coverage for this age group from 86.6% to 89.0%. MMR2 catch‐up activity in this age group was greater in the lowest socio‐economic status areas than in the highest status areas (29.1% v 7.6%), and also for Indigenous than for non‐Indigenous Australians (35.8% v 17.1%). MMR2 catch‐up activity in 2016 and 2017 peaked mid‐year. Conclusions: Linking family assistance payments with childhood vaccination status and associated program improvements were followed by substantial catch‐up vaccination activity, particularly in young people from families of lower socio‐economic status.

Brynley P Hull · Frank H Beard · Alexandra J Hendry · Aditi Dey · Kristine Macartney

The coronavirus disease 2019 (COVID‑19) pandemic has forced many countries to take extraordinary measures to prevent spread of disease. In New South Wales, public health orders introduced during 18–26 March 2020 required the closure of major industries and prohibited non‐essential gatherings of more than 100 people or allowing less than 4 m2 space per person. On 29 March, further public health orders prohibited people leaving home other than for work, study, shopping, medical care, or exercise.1,2 Changes in patterns of presentations to emergency departments (EDs) have been reported during COVID‐19 lockdowns overseas, including reduced numbers of patients with certain high acuity conditions, such as acute coronary syndrome (ACS) and stroke.3,4,5 Understanding the situation in Australia is important for public health policy during this and future pandemics. The Western Sydney Local Health District is a metropolitan health network in NSW of four hospitals (each with EDs) with a total capacity of 1925 beds, serving a catchment of 950 000 people. We analysed triage, International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) coding, and separations data for ED presentations during 29 March – 31 May in each of 2019 and 2020. Differences in mean daily presentation numbers for each triage category and selected presentation types were assessed in non‐paired Student t test with Bonferroni correction. All data analysis was performed in Excel (Microsoft). As a quality assurance project, the study was exempted from formal ethics approval. The number of ED presentations during 29 March – 31 May was almost 25% lower in 2020 than in 2019 (26 617 v 35 268). Presentation numbers in all triage categories were lower in 2020 (P < 0.001), except for category 1 (resuscitation) (506 v 445, 14% increase; P = 0.40). The proportion of patients discharged from the ED was greater in 2020 (60% v 53%) and that of patients who did not wait for treatment smaller (1% v 5%). The number of patients admitted to hospital was lower in 2020 than 2019 (8047 v 11 838), as were the proportions admitted to hospital (30% v 34%) (Box 1). ED presentations with fourteen selected diagnoses were further examined: common infectious diseases (infectious enteric disease, pneumonia), conditions frequently seen in EDs (wrist or hand fractures, femur fractures, appendicitis, renal calculi), conditions for which fewer ED presentations have been reported during COVID‐19 restrictions overseas (stroke or cerebral haemorrhage, ACS, chest pain, transient ischaemic attacks), and conditions that may be exacerbated or for which follow‐up in routine medical services may be reduced by COVID‐19 and its associated restrictions (mental health problems, substance misuse, malignancy). The numbers of presentations with infectious enteric disease, pneumonia, wrist or hand fractures, stroke or intracerebral haemorrhage, and chest pain not resulting in another diagnosis were lower in 2020 than in 2019. The numbers of presentations with ACS were similar. The number of presentations with mental health problems was higher in 2020 (daily mean, 8.4; standard deviation [SD], 3.1) than in 2019 (daily mean, 6.9; SD, 2.6; difference, +1.5 presentations per day; 95% confidence interval, +0.1–2.9) (Box 2; online Supporting Information). Social distancing may have reduced the spread of infectious enteric diseases and community‐acquired pneumonia, and home isolation may have led to fewer fractures. However, lower numbers of presentations with chest pain or stroke (also reported overseas4) may reflect factors other than lower incidence, such as suspension of outpatient clinics and elective procedures, social distancing measures, and public anxiety. COVID‐19 has profoundly affected health care delivery. We found concerning reductions in ED presentation numbers that may indicate delayed seeking of appropriate medical attention. Public health messages should encourage timely presentation of people with time‐sensitive, potentially life‐threatening conditions, even during pandemics. Equally concerning is the higher number mental health‐related presentations, which may reflect anxiety about COVID‐19, loss of job security, or prolonged isolation. Studies of patients presenting to health care services as they re‐open are required to fully appreciate the health implications of the COVID‐19 epidemic. Box 1 – Emergency department presentations to Western Sydney Local Health District hospitals during corresponding two‐month periods in 2019 and 2020 Triage category Resuscitation Emergency Urgent Semi‐urgent Non‐urgent Total 29 March – 31 May 2019 Total number of presentations 445 8910 12 464 10 726 2723 35 268 Daily presentations, mean (standard deviation) 7.0 (3.2) 139 (15.9) 195 (19.3) 168 (22.3) 42.5 (10.7) 551 (41.8) Admitted to hospital 350 (79%) 4550 (51%) 4524 (36%) 2156 (20%) 258 (9%) 11 838 (34%) Discharged: treatment complete 38 (9%) 3350 (38%) 6155 (49%) 7093 (66%) 2039 (75%) 18 675 (53%) Transferred to another hospital or service 26 (6%) 521 (6%) 577 (5%) 299 (3%) 68 (2%) 1491 (4%) Did not wait 0 65 (1%) 560 (4%) 735 (7%) 239 (9%) 1599 (5%) Discharged against medical advice 7 (2%) 413 (5%) 646 (5%) 442 (4%) 81 (3%) 1589 (5%) Died in emergency department/dead on arrival 24 (5%) 11 (< 1%) 2 (< 1%) 1 (< 1%) 38 (1%) 76 (< 1%) 29 March – 31 May 2020 Total number of presentations 506 7609 9095 7346 2061 26 617 Daily presentations, mean (standard deviation) 7.9 (2.6) 119 (18.4) 142 (17.5) 115 (17.9) 32.2 (8.4) 416 (40.6) Admitted to hospital 370 (73%) 3112 (41%) 3072 (34%) 1279 (17%) 214 (10%) 8047 (30%) Discharged: treatment complete 62 (12%) 3836 (50%) 5146 (57%) 5324 (72%) 1525 (74%) 15 893 (60%) Transferred to another hospital or service 26 (5%) 424 (6%) 461 (5%) 304 (4%) 136 (7%) 1351 (5%) Did not wait 0 22 (< 1%) 84 (1%) 170 (2%) 107 (5%) 383 (1%) Discharged against medical advice 9 (2%) 210 (3%) 328 (4%) 267 (4%) 64 (3%) 878 (3%) Died in emergency department/dead on arrival 39 (8%) 5 (< 1%) 3 (< 1%) 0 15 (1%) 62 (< 1%) Change in presentation numbers, 2020 v 2019 +14% –15% –17% –32% –25% –25% table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Mean changes (with 95% confidence intervals) for numbers of emergency department presentations with selected diagnoses (ICD‐10‐AM codes), 29 March – 31 May 2020 v 29 March – 31 May 2019 ICD-10-AM = International Classification of Diseases, tenth revision, Australian modification. * Not resulting in another diagnosis. † Excluding cases without mention of obstruction.

Andrew W Kam · Sarah G Chaudhry · Nathan Gunasekaran · Andrew JR White · Matthew Vukasovic · Adrian T Fung

Collecting nasal samples with 3D-printed swabs is feasible, acceptable to patients and health carers, and convenient

Eloise Williams · Katherine Bond · Nicole Isles · Brian Chong · Douglas Johnson · Julian Druce · Tuyet Hoang · Susan A Ballard · Victoria Hall · Stephen Muhi · Kirsty L Buising · Seok Lim · Dick Strugnell · Mike Catton · Louis B Irving · Benjamin P Howden · Eric Bert · Deborah A Williamson

Objective: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone‐equivalent). Design: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. Participants, setting: People aged 12 years or more treated for asthma during 2014–2018, according to dispensing of controller inhaled corticosteroids (ICS). Main outcome measures: Number of people dispensed OCS for managing asthma during 2014–2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone‐equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone‐equivalent during 2018, stratified by inhaler controller dose and use. Results: 124 011 people had been dispensed at least two prescriptions of ICS during 2014–2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone‐equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone‐equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone‐equivalent or more, for 2316 of whom (50%) controller use was inadequate. Conclusions: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one‐quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Mark Hew · Vanessa M McDonald · Phil G Bardin · Li Ping Chung · Claude S Farah · Amanda Barnard · Mark S Cooper · Peter G Gibson · John W Upham

It has been reported that about 60% of patients commencing chemotherapy in Australia with curative intent and 47% of those receiving radiotherapy also use complementary medicine.1,2 Ingestible products are frequently used, but are often not discussed with the medical team, which increases the risk of interactions and other undesirable effects. Opportunity costs are another problem; while complementary medicine is typically used by people with cancer for supportive care and wellbeing, some use it to help treat cancer.2 Given the frequent use of complementary medicine by people with cancer, we surveyed Australian public and private hospitals with dedicated cancer services (1 May – 15 December 2016),3,4 to assess various aspects of cancer service coverage, particularly complementary medicine services. In this report, we describe hospital policies on complementary medicine and the availability of related information for patients. The study was approved by the human research ethics committees of the University of Western Sydney (reference, H11389), the University of Wollongong and Illawarra Shoalhaven Local Health District (reference, HREC/16/WGONG/178), and Calvary Health Care, Adelaide (reference, 16‐CHREC‐E011). One staff member from the cancer service of each participating hospital (262 of 282 invited hospitals, 93%) completed a 52‐item electronic survey (online Supporting Information). Chemotherapy was provided by 207 of the participating services (79%) and supportive and allied health care by 196 (75%), including 66 (25%) that provided at least one type of complementary medicine service. Palliative care was provided by 168 hospitals (64%), surgery by 143 (55%), and radiotherapy by 143 (34%). Ninety‐three responding hospitals (36%) could not provide responses to one or more of the five policy‐related survey questions. This was despite the option to complete the survey across several log‐in sessions and 223 of the respondents (85%) having administrator or management roles. Only 89 respondents (34%) were aware of the Council of Australian Therapeutic Advisory Groups (CATAG) position statement on complementary medicines,5 and only 31 of these respondents (35%) thought that their hospital policies were aligned with this statement. A substantial proportion of hospitals did not have policies regarding complementary medicine practitioners or patient‐initiated complementary medicine use (Box). Most hospitals (229, 87%) had policies for documenting complementary medicines: 76 (33%) documented all complementary medicines (including patient‐initiated products) on medication charts, 88 (38%) documented only complementary medicines approved by medical staff, and 48 (21%) documented complementary medicine use only in the clinical history. The policy at 17 hospitals (6%) was that complementary medicines were never permitted, despite CATAG advice.5 In an adjusted backward multinominal logistic regression analysis, hospitals with cancer services without complementary medicine services were significantly less likely to have policies on complementary medicine practitioners and documenting complementary medicines (Box). Further, only 123 services (47%) provided complementary medicine information for patients, and 23 respondents (9%) did not know whether such information was available. The differences in the awareness of and the availability of hospital policies and patient information about complementary medicine are concerning. Irrespective of whether a cancer service provides complementary medicine, consistent policies across Australian hospitals, and staff and patient awareness of these policies, are important because of the widespread use of complementary medicine. Stronger leadership is needed from peak bodies, such as the Australian Commission on Safety and Quality in Health Care and CATAG, to encourage Australian cancer services and hospitals to update or review their complementary medicine policies. Box – Hospital policies regarding complementary medicine products and visiting practitioners, based on survey responses from 262 hospitals with cancer services Complementary medicine (CM) cancer services available Hospitals without v with CM service: adjusted odds ratio* (95% CI) Policy type Number Yes No Total number of hospitals 262 66 (25%) 196 (75%) Documenting CM product use Hospital policy 229 (87%) 60 (91%) 169 (86%) — No policy 24 (9%) 1 (2%) 23 (12%) 10.4 (1.3–81) Unknown 9 (3%) 5 (8%) 4 (2%) 0.29 (0.07–12) Documenting patient‐initiated CM products Hospital policy 43 (16%) 15 (23%) 28 (14%) — No policy 133 (51%) 30 (45%) 103 (53%) 1.8 (0.84–4.0) Case‐by‐case 43 (16%) 9 (14%) 34 (17%) 1.2 (0.48–3.3) Unknown 43 (16%) 12 (18%) 31 (16%) 1.8 (0.68–5.0) Referrals to CM practitioners outside the hospital Hospital policy 25 (10%) 14 (21%) 11 (6%) — No policy 145 (55%) 27 (41%) 118 (60%) 5.2 (2.1–13) Case‐by‐case 43 (16%) 15 (23%) 28 (14%) 2.8 (0.99–8.0) Unknown 49 (19%) 10 (15%) 39 (20%) 4.4 (1.5–13) Scope of practice for visiting CM practitioners Hospital policy 54 (21%) 20 (30%) 34 (17%) — No policy 113 (43%) 16 (24%) 97 (49%) 3.3 (1.5–7.3) Case‐by‐case 34 (13%) 17 (26%) 17 (9%) 0.65 (0.26–1.6) Unknown 61 (23%) 13 (20%) 48 (24%) 2.1 (0.95–5.0) Credentialing for visiting CM practitioners Hospital policy 72 (28%) 32 (48%) 40 (20%) — No policy 103 (39%) 11 (17%) 92 (47%) 6.2 (2.8–14) Case‐by‐case 28 (11%) 11 (17%) 17 (9%) 1.4 (0.56–3.5) Unknown 59 (22%) 12 (18%) 47 (24%) 2.9 (1.3–6.6) CI = confidence interval. * Reference category: hospital has policy and its cancer service provides complementary medicine services. Derived by backward multinominal logistic regression, adjusted for survey responder's role (administration/management: 46 [18%], health care professional: 70 [27%], dual role: 146 [56%]); hospital ownership (public: 132 [50%], private for‐profit: 74 [28%], private not‐for‐profit: 56 [21%]; and Australian Bureau of Statistics remoteness classification (major cities: 117 [40%], inner/outer regional: 87 [30%], remote/very remote: 91 [31%]).

Jennifer Hunter · Suzanne Grant · Geoff P Delaney · Caroline A Smith · Kate Templeman · Jane Ussher

Objective: To evaluate associations between exposure during early life to mine fire smoke and parent‐reported indicators of respiratory and atopic illness 2–4 years later. Design, setting: The Hazelwood coalmine fire exposed a regional Australian community to markedly increased air pollution during February – March 2014. During June 2016 – October 2018 we conducted a prospective cohort study of children from the Latrobe Valley. Participants: Seventy‐nine children exposed to smoke in utero, 81 exposed during early childhood (0–2 years of age), and 129 children conceived after the fire (ie, unexposed). Exposure: Individualised mean daily and peak 24‐hour fire‐attributable fine particulate matter (PM2.5) exposure during the fire period, based on modelled air quality and time‐activity data. Main outcome measures: Parent‐reported symptoms, medications use, and contacts with medical professionals, collected in monthly online diaries for 29 months, 2–4 years after the fire. Results: In the in utero exposure analysis (2678 monthly diaries for 160 children exposed in utero or unexposed), each 10 μg/m3 increase in mean daily PM2.5 exposure was associated with increased reports of runny nose/cough (relative risk [RR], 1.09; 95% CI, 1.02–1.17), wheeze (RR, 1.56; 95% CI, 1.18–2.07), seeking health professional advice (RR, 1.17; 95% CI 1.06–1.29), and doctor diagnoses of upper respiratory tract infections, cold or flu (RR, 1.35; 95% CI, 1.14–1.60). Associations with peak 24‐hour PM2.5 exposure were similar. In the early childhood exposure analysis (3290 diaries for 210 children exposed during early childhood, or unexposed), each 100 μg/m3 increase in peak 24‐hour PM2.5 exposure was associated with increased use of asthma inhalers (RR, 1.26; 95% CI, 1.01–1.58). Conclusions: Exposure to mine fire smoke in utero was associated with increased reports by parents of respiratory infections and wheeze in their children 2–4 years later.

Gabriela A Willis · Kate Chappell · Stephanie Williams · Shannon M Melody · Amanda Wheeler · Marita Dalton · Shyamali C Dharmage · Graeme R Zosky · Fay H Johnston

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation.

Jyoti Khadka · Renuka Visvanathan · Olga Theou · Max Moldovan · Azmeraw T Amare · Catherine Lang · Julie Ratcliffe · Steven L Wesselingh · Maria C Inacio