Research

Coronavirus disease 2019 (COVID‐19) and subsequent containment measures affected consumer behaviour in Australia, including the stockpiling of essential items. Increased demand for prescription medications caused concern about potential medication shortages, and a range of policies were implemented in March 2020 to protect supplies.1 We used interrupted time series modelling to quantify the impact of the COVID‐19 pandemic on medication dispensing. The Pharmaceutical Benefits Scheme (PBS) subsidises public medication costs in Australia. We analysed Section 85 date of supply data2 to model dispensing during January 2016 – December 2019, by month, separately for all PBS prescriptions, the ten medications most frequently dispensed during the 2018–19 financial year, hydroxychloroquine, and dexamethasone. These models, which accounted for long term trends and seasonal changes, were used to predict expected dispensing during January – June 2020 (with 95% confidence intervals [CIs]), which we compared with actual dispensing rates during this period (online Supporting Information). Ethics approval was not required for our analysis of publicly available data. The number of prescriptions dispensed during March 2020 was significantly higher than predicted (4.80 million more prescriptions, +18.5%; 95% CI, +14.0% to +23.3%), but significantly lower in April (2.28 million fewer prescriptions, –9.2%; 95% CI, –5.3% to –12.8%) and May (2.08 million fewer prescriptions; –8.1%; 95% CI, –4.3% to –11.5%); there was no significant difference in June 2020 (988 778 fewer prescriptions, –3.8%; 95% CI, –7.5% to +0.1%) (Box). A similar pattern applied to the ten most dispensed medications; the increase in the number of hydroxychloroquine prescriptions dispensed in March was particularly large (24 286 more prescriptions, +95.5%; 95% CI, +89.1 to +102%) (Supporting Information). Increased dispensing of prescription medications in March 2020 was consistent with the general panic buying reported early in the COVID‐19 pandemic.3 Pharmacies also received increased requests for prescription and over‐the‐counter medications at this time, in some cases causing local shortfalls1 and concern that continued high dispensing might interrupt medication supply at the national level. This applied in particular to drugs considered early in the pandemic as potential treatments for COVID‐19, such as hydroxychloroquine. In response to increased dispensing in March, the Australian government rapidly implemented a range of policies for protecting medication supplies. Dispensing limits of one month’s supply were applied to medications if shortages would have serious health consequences.1 These policies reduced the total number of medications dispensed in April and May 2020, followed by the return to normal levels of prescription dispensing in June. Other factors likely to have been important were stockpiles amassed by people during March, public adjustment to the pandemic, and the early suppression of COVID‐19 in Australia. Restrictions on prescription dispensing were balanced by services to assist susceptible patients to isolate themselves; for example, the COVID‐19 home medicines service funded home delivery of prescription medications by community pharmacies and Australia Post,4 and funding for telehealth was increased to facilitate remote prescribing.5 Our findings indicate that medication supply can be safeguarded from panic dispensing by a range of regulatory policies combined with medication services for vulnerable people. This may be particularly important for ensuring equitable access to medications for treating COVID‐19. The risk of further COVID‐19 outbreaks underscores the importance of maintaining these policies and services. Box – Total number of prescriptions dispensed in Australia, January 2016 – June 2020, and numbers of COVID‐19 diagnoses in Australia, January 2020 – June 2020 CI = confidence interval. * Source: Australian Department of Health.2

Mustafa Mian · Subhashaan Sreedharan · Sarah Giles

Practitioners who prescribe opioid medications for people with chronic non‐cancer pain must navigate increasingly stringent policy requirements,1 research findings questioning the benefit of opioids for such patients,2 and patients who fear uncontrolled pain if opioids are withdrawn.3 In Australia and New Zealand, people with chronic non‐cancer pain may be referred to specialist pain management services, most of which participate in the electronic Persistent Pain Outcomes Collaboration (ePPOC; https://www.uow.edu.au/ahsri/eppoc), an initiative for collecting standardised information about their patients, the services they provide, and the outcomes of treatment. This information is used at point of care, and for reporting, benchmarking, and research. To explore the impact of changes in opioid use on outcomes for patients, we analysed ePPOC data collected at 67 pain services (online Supporting Information) during January 2015 – June 2020. We extracted data for all patients with completed episodes of care and who had answered questions about opioid use at referral and episode end. We summarised their characteristics and outcomes as means with standard deviations (SDs). All analyses were conducted in SAS 9.4. Our study was approved by the University of Wollongong and Illawarra and Shoalhaven Local Health District health and medical human research ethics committee; reference, 2019/ETH03804). The mean age of the 10 302 patients who provided information at both referral and at the end of their treatment episodes was 49.5 years (SD, 14.4 years); 5807 were women (56.4%), and 3490 had experienced their pain for more than five years (33.9%). The most frequent site of their main pain was the back (3936 patients; 38.2%). A total of 6340 patients (61.5%) were using opioid medications at referral (Box 1); their mean oral morphine equivalent daily dose4 was 56.3 mg (SD, 75.3 mg), the median daily dose was 31.0 mg (interquartile range [IQR], 15–75 mg). They reported higher mean pain scores than patients not using opioids at referral (6.2 [SD, 1.6] v 5.8 [SD, 1.7]) and greater interference in daily activities (7.2 [SD, 1.8] v 6.5 [SD, 2.0]; each measured with the Brief Pain Inventory5). Mean values for depression, anxiety, stress, pain catastrophising, and pain self‐efficacy were also worse for people using opioid medications (data not shown). The most frequent service events were individual appointments with medical and allied health staff (35 678 of 55 012 events, 65%) and group pain programs (18 841 events, 34%); there were 493 procedural interventions (1%). The median episode length was 175 days (IQR, 99–322 days). Opioid prescribing varies between pain services, including direct prescribing by the pain specialist and recommendations to patients’ general practitioners. However, a major focus of multidisciplinary care is supporting patients to reduce their opioid use, which typically involves collaboration between the patient, their GP, and the pain service. By the end of their treatment episodes, 1724 patients who reported using opioids at referral (27.2%) had stopped doing so, 1234 patients (19.5%) had reduced their dose by at least 50% and 3382 patients (53.3%) had either not changed, increased, or reduced opioid use by less than 50%. For each group, scores had improved in each clinical domain, and the changes were greatest for patients who had ceased opioid use, as were the proportions experiencing clinically significant improvement. Scores for measures specifically related to pain experience (pain severity, interference, catastrophising and self‐efficacy) at the end of treatment were similar to or better than those of patients who had not been using opioids at referral, despite greater initial pain severity. Conversely, the smallest mean improvements were for the patients who had not reduced opioid use by at least 50% (Box 2). Although our study was limited by its retrospective nature, the lack of follow‐up of patients who did not complete treatment, and its restriction to specialist pain practices, our findings are encouraging. We found that significant clinical improvements are possible for people with chronic non‐cancer pain attending multidisciplinary pain management services in Australia and New Zealand, even as they discontinue opioid medications. The challenge is to extend these services and supported self‐management skills to primary and community care. Box 1 – Opioid use by patients at referral and at the end of treatment in specialist pain clinics * Opioid therapy was initiated for 536 of patients who had not being using opioid medications at referral (13.5%). † Opioid use had been reduced by less than 50% for 1025 patients (30.3%), not changed for 878 patients (26.0%), and increased for 1479 patients (43.7%). Box 2 – Mean pain and psychometric scores, and changes in scores between referral and end of treatment (with standard deviations), by opioid use at the two time points table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Clinical domain Patients not using opioids at referral Patients who were using opioids at referral Ceased taking opioids Reduced opioid use by at least 50% Other* Total number of patients 3962 1724 1234 3382 Pain severity (BPI5) 3787 1646 1174 3215 Referral 5.8 (1.7) 6.1 (1.7) 6.3 (1.6) 6.3 (1.6) Episode end 4.9 (2.0) 4.9 (2.0) 5.5 (1.8) 5.8 (1.7) Change in score –0.9 (1.7) –1.2 (1.8) –0.8 (1.6) –0.5 (1.5) Clinically significant improvement† 817/2997 (27%) 459/1410 (33%) 231/1035 (22%) 436/2827 (15%) Pain interference (BPI5) 3905 1702 1219 3316 Referral 6.5 (2.0) 7.1 (1.8) 7.3 (1.7) 7.2 (1.9) Episode end 4.9 (2.4) 5.0 (2.4) 5.7 (2.3) 6.2 (2.2) Change in score –1.6 (2.2) –2.1 (2.3) –1.6 (2.1) –1.0 (2.0) Clinically significant improvement† 2050/3279 (63%) 1062/1546 (69%) 679/1133 (60%) 1481/3003 (49%) Depression (DASS‐216) 3827 1673 1201 3240 Referral 17.8 (12.1) 20.2 (12.4) 20.9 (12.6) 20.7 (12.4) Episode end 12.8 (11.1) 13.8 (11.6) 15.6 (12.0) 16.6 (11.9) Change in score –5.0 (10.1) –6.4 (11.0) –5.3 (10.7) –4.0 (10.2) Clinically significant improvement† 1308/2231 (59%) 662/1100 (60%) 434/810 (54%) 1042/2190 (48%) Anxiety (DASS‐216) 3821 1676 1191 3233 Referral 12.1 (10.2) 13.3 (10.4) 14.1 (10.4) 13.7 (10.3) Episode end 10.1 (9.5) 10.9 (9.7) 11.9 (9.7) 12.5 (10.1) Change in score –2.0 (8.2) –2.4 (8.7) –2.2 (8.4) –1.2 (8.0) Clinically significant improvement† 858/1972 (44%) 438/962 (46%) 288/716 (40%) 662/1904 (35%) Stress (DASS‐216) 3818 1660 1191 3226 Referral 19.8 (11.0) 21.1 (10.8) 21.9 (10.9) 21.2 (11.1) Episode end 15.6 (10.6) 16.6 (10.7) 17.9 (10.5) 18.6 (10.8) Change in score –4.1 (9.6) –4.5 (10.2) –4.0 (9.3) –2.6 (9.2) Clinically significant improvement† 1154/1936 (60%) 553/905 (61%) 387/710 (55%) 898/1828 (49%) Pain catastrophising (PCS7) 3796 1649 1174 3204 Referral 26.3 (13.3) 28.1 (13.4) 28.5 (13.4) 28.3 (13.3) Episode end 18.3 (13.3) 17.9 (13.5) 20.9 (13.6) 22.1 (13.6) Change in score –8.0 (11.6) –10.2 (12.2) –7.6 (11.1) –6.2 (11.2) Clinically significant improvement† 1425/2513 (57%) 714/1164 (61%) 435/841 (52%) 1056/2308 (46%) Pain self‐efficacy (PSEQ8) 3860 1685 1210 3262 Referral 24.0 (12.6) 20.6 (12.0) 18.6 (11.0) 18.9 (11.9) Episode end 32.1 (14.4) 32.0 (14.4) 26.9 (13.1) 24.0 (13.1) Change in score +8.1 (12.7) +11.5 (14.0) +8.3 (12.7) +5.1 (12.1) Clinically significant improvement† 1433/2796 (51%) 827/1382 (60%) 504/1058 (48%) 1015/2773 (37%) BPI = Brief Pain Inventory (range, 0–10); DASS‐21 = Depression Anxiety and Stress Scale (range, 0–42); PCS = Pain Catastrophising Scale (range, 0–52); PSEQ = Pain Self‐Efficacy Questionnaire (range, 0–60; higher scores indicate greater self‐efficacy). * Opioid use by patients had been reduced by less than 50%, not changed, or increased. † For patients who reported at least moderate symptom severity at referral (see Supporting Information for definitions of clinically significant improvement).

Hilarie Tardif · Christopher Hayes · Samuel F Allingham

Objective: To assess the analgesic efficacy and safety of single‐dose oral cannabidiol (CBD) as an adjunct to standard care for patients presenting to an emergency department with acute low back pain. Design: Randomised, double blinded, placebo‐controlled clinical trial. Setting: The tertiary emergency department of Austin Hospital, Melbourne. Participants: Patients who presented with acute, non‐traumatic low back pain between 21 May 2018 and 13 June 2019. Intervention: One hundred eligible patients were randomised to receiving 400 mg CBD or placebo in addition to standard emergency department analgesic medication. Main outcome measures: Pain score two hours after administration of study agent, on a verbal numerical pain scale (range, 0‒10). Secondary outcomes were length of stay, need for rescue analgesia, and adverse events. Results: The median age of the 100 participants was 47 years (IQR, 34‒60 years); 44 were women. Mean pain scores at two hours were similar for the CBD (6.2 points; 95% CI, 5.5–6.9 points) and placebo groups (5.8 points; 95% CI, 5.1–6.6 points; absolute difference, –0.3 points; 95% CI, –1.3 to 0.6 points). The median length of stay was 9.0 hours (IQR, 7.4‒12 hours) for the CBD group and 8.5 hours (IQR, 6.5‒21 hours) for the placebo group. Oxycodone use during the four hours preceding and the four hours after receiving CBD or placebo was similar for the two groups, as were reported side effects. Conclusion: CBD was not superior to placebo as an adjunct medication for relieving acute non‐traumatic low back pain in the emergency department. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000487213 (prospective).

Bronwyn Bebee · David M Taylor · Elyssia Bourke · Kimberley Pollack · Lian Foster · Michael Ching · Anselm Wong

In Australia, an estimated 12.7% of patients with ST‐elevation myocardial infarction (STEMI) die or have recurrent myocardial infarctions within 30 days of diagnosis.1 Prompt reperfusion reduces morbidity and mortality, and guidelines consequently aim to minimise the time between symptom onset and reperfusion.1,2,3 Patients with chest pain may arrange their own transport to an emergency department or travel by ambulance. The risk period is shorter for patients without access to a defibrillator when they travel by ambulance, and they receive initial management more promptly. In Australia, only one in two patients with STEMI calls an ambulance.4 Characterising patients less likely to call an ambulance would inform targeted public health efforts to improve this situation. We analysed data contributed by 43 hospitals across Australia to the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE)5 for patients with confirmed STEMI who presented to these hospitals during 23 February 2009 – 31 December 2017. We excluded patients who experienced out‐of‐hospital cardiac arrest or cardiogenic shock. We compared the clinical characteristics, time to reperfusion, and hospital outcomes, including death and major adverse cardiovascular events (MACE) — cardiac death, myocardial infarction, heart failure, or shock — for patients who arrived by ambulance or otherwise, after adjusting for Global Registry of Acute Coronary Events (GRACE) risk score6 at baseline. The statistical significance of differences in categorical variables was assessed in Rao–Scott χ2 tests and that of continuous variables in Wilcoxon rank‐sum tests. For adjusted analyses, we used multivariable logistic regression models in a generalised estimating equation (GEE) framework, adjusted for clustering by hospital. Analyses were conducted in SAS 9.4. Ethics approval for the study was granted by the Concord Repatriation General Hospital Human Research Ethics Committee (reference, HREC/08/CRGH/180). Of 2765 patients who presented with STEMI to CONCORDANCE hospitals during 2009–2017, 1616 (58.4%) arrived by ambulance and 1149 (41.6%) by other means. The median age of patients arriving by ambulance (64 years; interquartile range [IQR], 54–74 years) was higher than for the other patients (59 years; IQR, 51–67 years), and the proportions with hypertension, a family history of coronary heart disease, or prior myocardial infarction, atrial fibrillation, or stroke/transient ischaemic attack were larger (Box). Time between arrival at hospital and reperfusion (primary percutaneous intervention or fibrinolysis) was significantly shorter for patients who arrived by ambulance than for other patients (Box). After adjusting for GRACE risk score, the odds of death (adjusted odds ratio [aOR], 1.16; 95% confidence interval [CI], 0.65–2.08) and MACE (aOR, 0.89; 95% CI, 0.72–1.10) were similar for the two patient groups (Supporting Information). Our analysis of data from a large Australian registry indicates that fewer than 60% of patients with STEMI arrive at hospital by ambulance; those who do have a higher median age and larger proportions have histories of cardiovascular disease. Importantly, their median time to reperfusion is shorter than for those not arriving by ambulance, probably because STEMI is diagnosed by electrocardiography during their journey to the hospital, which facilitates priming of emergency departments (for fibrinolysis) and catheterisation laboratories (for percutaneous coronary intervention). Despite the less favourable risk profiles of patients who arrive by ambulance, their hospital outcomes are comparable with those of patients who present directly to hospital, presumably because of their more rapid access to reperfusion. Our finding that patients with STEMI who are older and have more comorbid conditions are more likely to call an ambulance is not novel,7 but does indicate that this has not changed in recent years. This underscores the value of calling an ambulance when chest pain develops, and suggest that this public health message should be more actively promoted. Box – Baseline characteristics and times to reperfusion of 2765 patients who presented with STEMI to CONCORDANCE hospitals, 2009–2017 table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Transport to hospital Characteristic Ambulance Other means P Number of patients 1616 (58.4%) 1149 (41.6%) Age (years), median (IQR) 64 (54‒74) 59 (51‒67) < 0.001 Sex (men) 1140 (71%) 933 (81%) < 0.001 English as first language 1383 (86%) 959 (83%) 0.44 Prior myocardial infarction 252 (16%) 151 (13%) 0.046 Prior heart failure 49 (3%) 27 (2%) 0.27 Prior percutaneous coronary intervention 177 (11%) 116 (10%) 0.46 Prior coronary artery bypass graft 52 (3%) 26 (2%) 0.10 Prior atrial fibrillation 96 (6%) 30 (3%) < 0.001 Prior bleeding 17 (1%) 14 (1%) 0.63 Chronic renal failure 73 (5%) 42 (4%) 0.17 Prior stroke/transient ischaemic attack 94 (6%) 32 (3%) < 0.001 Diabetes 321 (20%) 232 (20%) 0.80 Hypertension 853 (53%) 534 (47%) < 0.001 Dyslipidaemia 696 (43%) 473 (41%) 0.21 Family history of coronary heart disease 514 (32%) 477 (42%) < 0.001 Grace risk score (Fox), median (IQR) 114 (95‒135) 102 (85‒119) < 0.001 Reperfusion modality Primary percutaneous coronary intervention 919 (57%) 486 (42%) < 0.001 Fibrinolysis 434 (27%) 442 (38%) < 0.001 None 320 (20%) 273 (24%) 0.010 Hospital arrival to reperfusion (h), median (IQR) Primary percutaneous coronary intervention 1.2 (0.7‒2.1) 2.1 (1.4‒6.1) < 0.001 Fibrinolysis 0.6 (0.3‒1.3) 0.8 (0.5‒1.3) 0.002 IQR = interquartile range; STEMI = ST‐elevation myocardial infarction.

Eleanor Redwood · Karice Hyun · John K French · Leonard Kritharides · Mark Ryan · Derek P Chew · Mario D'Souza · David B Brieger

Many patients had persistent symptoms two months after diagnosis, including fatigue, chest pain, and breathlessness

David R Darley · Gregory J Dore · Lucette Cysique · Kay A Wilhelm · David Andresen · Katrina Tonga · Emily Stone · Anthony Byrne · Marshall Plit · Jeffrey Masters · Helen Tang · Bruce Brew · Philip Cunningham · Anthony Kelleher · Gail V Matthews

In June 2015, 41% of Australian medical specialists were women,1 but only 28% of those in senior or leadership positions.2 Academic research is important for obtaining tenure and promotion in medicine. First authorship on publications is typically granted to junior authors and last authorship to directing senior authors. The proportion of women among first authors in six prominent American medical journals increased from 5.9% in 1970 to 29.3% in 2004, and for last authorship from 3.7% to 19.3%.3 However, a 2016 study found that the proportion of authors who were women in high impact medical journals had plateaued or declined since 2009.4 Examining Australian patterns of authorship could help identify barriers to the academic advancement of women in medicine. We identified in PubMed all journal articles published during 2005–2018 by the eight journals associated with peak bodies of Australian medical practitioners, and used the validated genderize. R tool to determine the probable gender of authors’ first names.5 We used Poisson regression to analyse first and last authorship (male = 0, female = 1) by year; we report the statistical significance of the deviation of the regression slope (B‐value) from zero. The relationship between number of authors and gender were assessed by linear regression, including an interaction term between gender and time. Formal ethics approval was not required for this analysis of publicly available data. Gender could be determined with at least 50% probability for the first authors of 26 621 of 27 804 articles (96%) and the last authors of 26 972 (97%). Between 2005 and 2018, the proportion of women among first authors in the eight journals increased from 522 of 1600 (32.6%) to 899 of 2391 (37.6%; P < 0.001); the proportion among last authors did not change (28.0%). The proportions of women among both first and last authors increased significantly in the Journal of Paediatrics and Child Health, the Australian and New Zealand Journal of Obstetrics and Gynaecology, and the Medical Journal of Australia, as did those of first authors (but not last authors) in the Australian and New Zealand Journal of Public Health, Emergency Medicine Australasia, the Australian and New Zealand Journal of Psychiatry, and the Australian and New Zealand Journal of Surgery; the proportions of neither changed significantly in Australian Family Physician (Box; Supporting Information, table 1). The mean number of authors on publications with women as first authors (3.8; standard deviation [SD], 2.4) was higher than for those with men as first authors (3.3; SD, 2.4; P < 0.001). The difference between author numbers was smaller, but statistically significant, with respect to last author gender (women: mean number of authors, 3.6; SD, 2.4; men: 3.5; SD, 2.4; P = 0.045) (Supporting Information, tables 2, 3). Our study did not distinguish between research, review, and other journal article types. While our findings may reflect overall involvement of women in research, they do not specifically define gender proportions among leaders of high impact academic research programs. The increase in the proportion of first authors of Australian medical journal articles who are women may reflect the rise in the proportion of female doctors from 33% to 43% between January 2006 and December 2018.1 It is also possible that women, under‐represented in their specialties, feel greater pressure than men to publish as first authors for purposes of career progression.2 Our data indicate that the proportion of women as first authors has increased, but that of last authorship has grown only in some specialities. Box – Proportions of women as first and last authors of articles in selected Australian medical journals, 2005–2018* * The raw data are included in the online Supporting Information, tables 4 and 5. † From 2018: the Australian Journal of General Practice.

Matthew J Lennon · Rose Kennedy · Hannah Ryan · Dennis R Neuen · Melissa Godwin

Objective: To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation‐capable hospital is associated with better outcomes for patients with ACS. Design, setting: Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data. Setting, participants: Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation‐capable hospitals), February 2009 – October 2018. Main outcome measures: Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all‐cause deaths in hospital and by six and 12‐ or 24‐month follow‐up. Results: The proportion of women among the 5637 patients who presented to catheterisation‐capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation‐capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all‐cause death in hospital and by 6‐ and 12‐ or 24‐month follow‐up. Conclusions: Although a larger proportion of patients who presented to catheterisation‐capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

Michael Ayad · Karice Hyun · Mario D’Souza · Julie Redfern · Janice Gullick · Mark Ryan · David B Brieger

Objectives: To describe patterns of care in New South Wales for men with prostate cancer, and to ascertain factors associated with receiving different types of treatment. Design: Individual patient data record linkage study. Setting, participants: 4003 New South Wales men aged 45 years or more enrolled in the population‐based 45 and Up Study in whom prostate cancer was first diagnosed during 2006–2013. Main outcome measures: Prostate cancer treatment type received; factors statistically associated with treatment received; proportions of patients who consulted radiation oncologists prior to treatment. Results: In total, 1619 of 4003 patients underwent radical prostatectomy (40%), 893 external beam radiotherapy (EBRT) (22%), 183 brachytherapy (5%), 87 chemotherapy (2%), 373 androgen deprivation therapy alone (9%), and 848 no active treatment (21%). 205 of 1628 patients who had radical prostatectomies (13%) had radiation oncology consultations prior to surgery. Radical prostatectomy was more likely for patients aged 45–59 years, with regional stage disease, living 100 km or more from the nearest radiotherapy centre, having partners, or having private health insurance, while lower physical functioning, obesity, and living in areas of greater socio‐economic disadvantage reduced the likelihood. EBRT was more likely for patients aged 70–79 years, with non‐localised or unknown stage disease, living less than 100 km from the nearest radiotherapy centre, or not having private health insurance, while the likelihood was lower for patients aged 45–59 years or more than 80 years and for those who had several comorbid conditions. Conclusions: Men with prostate cancer were twice as likely to have radical prostatectomy as to receive EBRT, and fewer than one in seven had consulted radiation oncologists prior to prostatectomy. The treatment received was influenced by several socio‐demographic factors. Given the treatment‐specific side effects and costs, policies that affect access to different treatments for prostate cancer should be reviewed.

Mei Ling Yap · Dianne L O'Connell · David E Goldsbury · Marianne F Weber · David P Smith · Michael B Barton

Objectives: To assess the efficacy of a pro‐active, absolute cardiovascular risk‐guided approach to opportunistically modifying cardiovascular risk factors in patients without coronary ischaemia attending a chest pain clinic. Design: Prospective, randomised, open label, blinded endpoint study. Setting: The rapid access chest pain clinic of Royal Hobart Hospital, a tertiary hospital. Participants: Patients who presented to the chest pain clinic between 1 July 2014 and 31 December 2017 who had intermediate to high absolute cardiovascular risk scores (5‐year risk ≥ 8%). Patients with known cardiac disease or from groups with clinically determined high risk of cardiovascular disease were excluded. Main outcome measures: The primary endpoint was change in 5‐year absolute risk score (Australian absolute risk calculator) at follow‐up (at least 12 months after baseline assessment). Secondary endpoints were changes in lipid profile, blood pressure, smoking status, and body mass index, and major adverse cardiovascular events. Results: The mean change in risk at follow‐up was +0.4 percentage points (95% CI, –0.8 to 1.5 percentage points) for the 98 control group patients and –2.4 percentage points (95% CI, –1.5 to –3.4 percentage points) for the 91 intervention group patients; the between‐group difference in change was 2.7 percentage points (95% CI, 1.2–4.1 percentage points). Mean changes in lipid profile, systolic blood pressure, and smoking status were larger for the intervention group, but not statistically different from those for the control group. Conclusions: An absolute cardiovascular risk‐guided, pro‐active risk factor management strategy employed opportunistically in a chest pain clinic significantly improved 5‐year absolute cardiovascular risk scores. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12617000615381 (retrospective).

J Andrew Black · Julie A Campbell · Serena Parker · James E Sharman · Mark R Nelson · Petr Otahal · Garry Hamilton · Thomas H Marwick

Early control of transmission was successful, but efforts to reduce further transmission remain important

Heather F Gidding · Dorothy A Machalek · Alexandra J Hendry · Helen E Quinn · Kaitlyn Vette · Frank H Beard · Hannah S Shilling · Rena Hirani · Iain B Gosbell · David O Irving · Linda Hueston · Marnie Downes · John B Carlin · Matthew VN O'Sullivan · Dominic E Dwyer · John M Kaldor · Kristine Macartney

Medicare Benefits Schedule (MBS) data indicated that there were 37% fewer screening procedures for breast cancers and 55% fewer for colorectal cancers in April than in March 2020.1 We examined the temporal relationship between coronavirus disease 2019 (COVID‐19)‐related restrictions in Victoria during 1 April – 15 October 2020 and cancer pathology notifications to the Victorian Cancer Registry (VCR), to estimate their impact on cancer diagnoses. Victorian legislation requires pathology services to notify reportable cancer diagnoses to the VCR.2 The E‐Path system, installed in all Victorian pathology services during 2013–2018,3 automatically transmits notifications to the VCR together with pathologist report authorisations. During 2019, 97 313 of 104 025 cancer pathology notifications to the VCR (94%) were received via E‐Path (data supplied by author LB). Changes to the E‐Path system during 2019 meant that we were unable to directly compare notification numbers for 2019 and 2020. We therefore modelled cancer incidence during 2014–2018 by Poisson regression. A spline function was fitted to VCR cancer incidence data for weeks 1–52, adjusted for day type (working or non‐working day/public holiday) and year, and the fitted curve used to predict daily incidence during 7 January – 15 October 2020. Predicted incidence was re‐scaled to estimate expected notification numbers; the scale factor was the number of notifications during the baseline period — 1 February – 16 March 2020, allowing a two‐week washout period before restrictions were formally announced — divided by the predicted incidence during this period. Observed and predicted notification numbers were compared using Poisson regression, with the expected number as an offset term, enabling estimation of relative reductions with 95% confidence intervals (CIs). Differences between predicted and actual notification numbers were estimated, both overall and for specific groups (eg, by tumour or age group), based on the pertinent incidence data. As a single cancer diagnosis can be associated with several pathology notifications, the number of undiagnosed cancers was estimated by multiplying the difference in notification numbers by the ratio of newly diagnosed tumours to pathology notifications in 2018 (Supporting Information, table 1). The confidence interval for the number of undiagnosed cases was based on the Poisson model, keeping the ratio of newly diagnosed tumours to pathology notifications constant. In sensitivity analyses, data were fitted to polynomial models, different baseline periods were used, or data were restricted to reportable cancer diagnoses. The study was exempted from formal ethics review by the human research ethics committee of Cancer Council Victoria. During 1 April – 15 October 2020, there were 5446 fewer notifications of new cancer diagnoses than predicted by our primary model (predicted, 54 609 v observed, 49 163; relative reduction, –10.0%; 95% CI, –10.8% to –9.2%) (Supporting Information, figure 1); we estimated that there were 2530 undiagnosed cancers (95% CI, 2327–2731). The relative reduction was greatest during 1 April – 4 May 2020 (Box 1). By tumour group, the relative reductions were most marked for prostate cancer, head and neck tumours, melanoma, and breast cancer; they were greater for men, people aged 50 years or more, and for people in areas of higher socio‐economic position (Box 2). The pattern of difference in notifications varied between tumour groups (Supporting Information, figure 2). The 6.5‐month period of COVID‐19‐related restrictions in Victoria was accompanied by a 10% reduction in cancer pathology notifications; we estimated that about 2530 cancer diagnoses were either delayed or missed. The impact of delayed diagnosis is greatest for patients with aggressive cancers. Changes in care delivery during the restrictions, including suspension of screening services and outpatient clinics and postponed surveillance of existing cancers, may have affected notification numbers for some tumour groups and consequently the estimated number of delayed diagnoses. Planning for a possible surge in cancer diagnoses over the coming 6–12 months, and media campaigns encouraging people to not further delay seeking medical attention, may ameliorate any negative impact of delayed cancer diagnosis. Box 1 – Cancer pathology notifications to the Victorian Cancer Registry, January–October 2020: observed (red) and predicted numbers (green), by day type LOESS = locally estimated scatterplot smoothing. The grey area marks the baseline period, the vertical dotted lines the analysis period for predicted notifications. A state of emergency was declared in Victoria on 16 March 2020. Stage 3 movement restrictions were applied from 30 March, eased on 13 May, and re‐applied from 8 July. The state of emergency was renewed on 2 August, together with application of stage 4 restrictions to metropolitan Melbourne until their easing from 19 October. For further details, see the footnote to figure 2 in the online Supporting Information. Box 2 – Cancer pathology notifications and estimated numbers of undiagnosed reportable cancers, 1 April – 15 October 2020* table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Notifications Relative difference (95% CI) Absolute difference (a) Tumour to notification ratio (b) Estimated number of undiagnosed tumours (a*b) Characteristic Predicted Observed All notifications 54 609 49 163 –10.0% (–10.8% to –9.2%) –5446 0.465 2530 Sex† Males 15 458 14 190 –8.2% (–9.7% to –6.7%) –1268 0.427 541 Females 10 408 10 367 –0.4% (–2.3% to 1.5%) –41 0.434 18 Age at diagnosis (years) < 50 9981 9674 –3.1% (–5.0% to –1.1%) –307 0.454 139 50–74 30 949 27 555 –11.0% (–12.0% to –9.9%) –3394 0.447 1516 ≥ 75 13 697 11 934 –12.9% (–14.4% to –11.3%) –1763 0.514 906 Tumour group Breast 7923 7130 –10.0% (–12.1% to –7.9%) –793 0.380 301 Colorectal 5063 4838 –4.4% (–7.1% to –1.7%) –225 0.501 113 Haematologic 10 011 9321 –6.9% (–8.8% to –5.0%) –690 0.234 162 Melanoma 7168 6217 –13.3% (–15.4% to –11.1%) –951 0.538 511 Lung 2967 3062 3.2% (–0.4% to 6.9%) 95 0.483 –46 Head and neck 1363 1155 –15.3% (–20.0% to –10.3%) –208 0.504 105 Bladder 2159 2009 –6.9% (–10.9% to –2.8%) –150 0.370 56 Prostate 6417 4770 –25.7% (–27.8% to –23.5%) –1647 0.560 922 All other 11 931 10 661 –10.6% (–12.3% to –8.9%) –1270 0.546 693 Socio‐economic position (quintile)‡ 1 (most disadvantaged) 10 334 9789 –5.3% (–7.1% to –3.4%) –545 0.453 247 2 10 378 9447 –9.0% (–10.8% to –7.1%) –931 0.456 425 3 10 192 9624 –5.6% (–7.4% to –3.7%) –568 0.488 277 4 10 925 9463 –13.4% (–15.1% to –11.6%) –1462 0.455 665 5 (least disadvantaged) 11 385 9714 –14.7% (–16.4% to –13.0%) –1671 0.460 769 Remoteness¶ Major cities 37 506 33 753 –10.0% (–11.0% to –9.0%) –3753 0.461 1731 Inner regional 13 414 12 031 –10.3% (–11.9% to –8.7%) –1383 0.472 652 Outer regional/remote 2553 2457 –3.8% (–7.5% to 0.1%) –96 0.472 45 CI = confidence interval. * Poisson regression (spline function, adjusted for day type [working day or non‐working day/public holiday] and year; baseline period: 1 February – 16 March 2020). † For cancers common in both sexes (melanoma, colorectal cancer, lung, head and neck cancers, haematological malignancies). ‡ Based on residential address, using the Google Geocoding API (https://developers.google.com/maps/documentation/geocoding/overview), spatially joined to Australian Bureau of Statistics Statistical Area 1 (SA1) polygons.4 Area‐based socio‐economic quintiles were based on 2016 Australian Bureau of Statistics census data.5 ¶ Accessibility and Remoteness Index of Australia.6

Luc te Marvelde · Rory Wolfe · Grant McArthur · Louis A Blake · Sue M Evans

Objective: To describe the clinical and procedural outcomes of per‐oral endoscopic myotomy (POEM) for achalasia in Australia. Design, setting: Prospective observational study in three Australian tertiary referral centres, 5 May 2014 – 27 October 2019 (66 months). Participants: Patients who had undergone POEM for achalasia. Major outcome measures: Eckardt scores calculated prior to POEM and six months, one year, and two years after POEM. The primary outcome was clinical success, defined as an Eckardt score of 3 or less without a second intervention. Results: 142 patients underwent POEM for achalasia; their mean age was 52 years (SD, 18 years), 83 were men (58%), and the median length of hospital stay two days (IQR, 1–3 days). Their mean Eckardt score before POEM was 8.0 (SD, 2.4) and 1.1 (SD, 1.6) six months after POEM; it did not change significantly between six months and two years after POEM (mean monthly increase, 0.014 points; 95% CI, –0.001 to 0.029). A total of 127 patients (89%) improved clinically after POEM. Intra‐procedural capnoperitoneum was the only risk factor associated with treatment failure (adjusted hazard ratio, 2.85; 95% CI, 1.08–7.51). Previous treatments — botulinum toxin injection (25 patients, 18%), endoscopic balloon dilatation (69, 49%), and Heller myotomy (14, 10%) — did not affect POEM outcomes. Five patients (4%) experienced major adverse events, including pneumonia, oesophageal leak, empyema and melaena, that were managed during admission and without sequelae. Conclusions: POEM is an effective treatment for achalasia. Significant reductions in Eckardt scores achieved by six months are sustained at two years. POEM can be both a first line definitive therapy and a salvage therapy for patients not helped by other treatments.

Sunil Gupta · Mayenaaz Sidhu · Xuan Banh · Joseph Bradbear · Karen Byth · Luke F Hourigan · Spiro Raftopoulos · Michael J Bourke

Objective: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re‐admissions of patients recently discharged from hospital. Design, setting: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. Participants: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 ‒ 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. Intervention: Comprehensive face‐to‐face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. Major outcomes: Rates of unplanned, all‐cause hospital re‐admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. Results: By 12 months, there had been 282 re‐admissions among 177 control patients (incidence rate [IR], 1.65 per person‐year) and 136 among 129 intervention patients (IR, 1.09 per person‐year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52‒1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22‒0.94) and combined re‐admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48‒0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit‒cost ratio of 31:1. Conclusion: A collaborative pharmacist‒GP model of post‐hospital discharge medicines management can reduce the incidence of hospital re‐admissions and ED presentations, achieving substantial cost savings to the health system. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

Christopher R Freeman · Ian A Scott · Karla Hemming · Luke B Connelly · Carl M Kirkpatrick · Ian Coombes · Jennifer Whitty · James Martin · Neil Cottrell · Nancy Sturman · Grant M Russell · Ian Williams · Caroline Nicholson · Sue Kirsa · Holly Foot

Objectives: To determine the age‐standardised prevalence of inflammatory bowel disease (IBD) in a metropolitan area of Sydney, with a focus on its prevalence among older people. Design, setting: Population‐based epidemiological study of people with IBD in the City of Canada Bay, a local government area in the inner west of Sydney, during 1 March 2016 – 10 November 2016. Participants: Patients diagnosed with confirmed IBD according to the Copenhagen or revised Porto criteria. Main outcome measures: Crude prevalence of IBD, including Crohn disease and ulcerative colitis; age‐standardised prevalence of IBD, based on the World Health Organization standard population; prevalence rates among people aged 65 years or more. Results: The median age of 364 people with IBD was 47 years (IQR, 34–62 years); 185 were women (50.8%). The crude IBD prevalence rate was 414 cases (95% CI, 371–456 cases) per 100 000 population; the age‐standardised rate was 348 cases (95% CI, 312–385 cases) per 100 000 population. The age‐standardised rate for Crohn disease was 166 cases (95% CI, 141–192 cases) per 100 000 population; for ulcerative colitis, 148 cases (95% CI, 124–171 cases) per 100 000 population. The IBD prevalence rate in people aged 65 years or more was 612 cases (95% CI, 564–660 cases) per 100 000, and for those aged 85 years or more, 891 cases (95% CI, 833–949 cases) per 100 000; for people under 65, the rate was 380 cases (95% CI, 342–418 cases) per 100 000. Conclusions: We found that the prevalence of confirmed IBD in a metropolitan sample was highest among older people. Challenges for managing older patients with IBD include higher rates of comorbid conditions, polypharmacy, and cognitive decline, and the immunosuppressive nature of standard therapies for IBD.

Aviv Pudipeddi · Jeffrey Liu · Viraj Kariyawasam · Thomas J Borody · James L Cowlishaw · Charles McDonald · Peter Katelaris · Grace Chapman · Crispin Corte · Daniel A Lemberg · Cheng H Lee · Anil Keshava · John Napoli · Robert Clancy · Webber Chan · Sudarshan Paramsothy · Rupert Leong

The Royal Commission into Aged Care Quality and Safety has highlighted the high rates of polypharmacy and potential medication‐related harm in residential aged care facilities (RACFs) in Australia.1 Residential medication management review (RMMR) is a government‐funded service for facilitating quality use of medicines in RACFs.2 Previous studies have found that RMMRs by accredited pharmacists and general practitioners identify a mean of 2.7–3.9 medication‐related problems per resident, and 45–84% of pharmacists’ recommendations were accepted by GPs.3 Guidelines recommend that residents should generally receive an RMMR on entering an RACF and when their clinical circumstances change,4 but annual claims data5,6 and recent research indicate that not all residents receive RMMRs.7 We examined time to first RMMR after RACF entry by analysing data for the national historical cohort of the Registry of Senior Australians (ROSA).7 In ROSA, de‐identified data collected during aged care eligibility assessments are linked to information about government‐subsidised aged care services, general practice and allied health services subsidised under the Medicare Benefits Schedule (MBS), medicines subsidised under the Pharmaceutical Benefits Scheme (PBS), and the Australian Institute of Health and Welfare National Death Index.8 Non‐Indigenous people aged 65 years or more who first entered permanent residential care during 1 January 2012 – 31 December 2015, had received an entry‐into‐care assessment within 100 days, and had received at least one PBS‐subsidised medication during the preceding year were included. Recipients of Department of Veterans’ Affairs‐funded services and people who had previously undergone RMMRs (eg, during transition care) were excluded. The cumulative incidence function was used to determine time to first MBS claim lodged by GPs for RMMRs (item code 903) or Home Medicines Reviews (HMRs) (item code 900) after entry to permanent residential care, adjusted for competing events (death, or permanent departure from the first RACF for another reason) using the Fine–Gray method,9 with follow‐up to 31 December 2016. Statistical analyses were undertaken in SAS 9.4. The University of South Australia (reference, 200489) and Australian Institute of Health and Welfare (reference, E02018/1/418) Human Research Ethics Committees provided ethics approval for the study. A total of 176 390 residents in 2799 RACFs were followed for a median 479 days (interquartile range [IQR], 149–858 days). Median age at entry was 84 years (IQR, 79–88 years), 108 908 were women (61.7%), and 84 864 were living with dementia (48.1%). In the year preceding entry, residents received a median of 11 unique prescription medications (IQR, 8–16 medications); 109 765 (62.2%) had received at least one high risk medication (as defined by the United States Institute for Safe Medication Practices10), and 7912 (4.5%) had received HMRs in the 12 months prior to RACF entry. By three months after RACF entry, 19.1% of residents (Wald 95% confidence interval [CI], 18.9–19.3%) had received RMMRs, 11.8% (95% CI, 11.6–11.9%) had died without RMMRs, and 5.7% (95% CI, 5.6–5.8%) had left their RACF for other reasons without RMMRs. At 12 months, 43.1% (95% CI, 42.8–43.3%) had received RMMRs, 20.6% (95% CI, 20.5–20.8%) had died without RMMRs, and 9.0% (95% CI, 8.8–9.1%) had left without receiving RMMRs. By 24 months, 49.7% (95% CI, 49.5–50.0%) had received RMMRs, 25.8% (95% CI, 25.6–26.0%) had died without RMMRs, and 10.2% (95% CI, 10.1–10.4%) had left their first RACF for other reasons without receiving RMMRs (Box). The high burden of medication use at the time of RACF entry suggests that most residents could have benefited from RMMRs, but MBS claims for RMMRs were lodged for fewer than one in five residents within three months of RACF entry, and fewer than one in two within two years. Our findings are generalisable to all older Australians entering RACFs, as ROSA captures data for all people aged 65 years or more who access government‐subsidised permanent residential aged care in Australia. We could not determine why residents were not referred for RMMRs, nor the impact of recent program changes2 on RMMR uptake and resident outcomes. In 2014–15, fewer GP medication review claims were reimbursed under the MBS (54 803 RMMRs, 63 872 HMRs) than pharmacist claims (93 517 RMMRs, 72 607 HMRs).5,6 Analysing GP claims may underestimate the number of RMMR reports prepared by pharmacists because GP claims are submitted after the medication management plan is discussed with the resident or family, while pharmacist claims are submitted after the report is sent to the GP.7 MBS claims may not be lodged if the full RMMR process cannot be completed (eg, because the resident died, their clinical circumstances had changed, or the RMMR report was not received or followed up), or claiming may be overlooked. Linkage with pharmacist claims data at the individual resident level could facilitate investigation of these limitations. Despite RMMRs being a key means for minimising medication‐related harm, MBS claims for RMMRs are lodged for only a fraction of residents who enter RACFs. The potential underuse of the program may be a missed opportunity for identifying and resolving medication‐related problems in Australian RACFs. Box – Stacked cumulative incidence function for time to first residential medication management review (RMMR), for first two years of permanent residential care* RACF = residential aged care facility. * For 176 390 residents (in 2799 residential aged facilities) included in the Registry of Senior Australians.8

Janet K Sluggett · J Simon Bell · Catherine Lang · Megan Corlis · Craig Whitehead · Steven L Wesselingh · Maria C Inacio

The consequences of removing some restrictions may not be apparent for more than two months

Nick Scott · Anna Palmer · Dominic Delport · Romesh Abeysuriya · Robyn M Stuart · Cliff C Kerr · Dina Mistry · Daniel J Klein · Rachel Sacks‐Davis · Katie Heath · Samuel W Hainsworth · Alisa Pedrana · Mark Stoove · David Wilson · Margaret E Hellard

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